Temple Health Magazine

LEWIS KATZ SCHOOL OF MEDICINE AT TEMPLE UNIVERSITY | TEMPLE UNIVERSITY HEALTH SYSTEM

WINTER 2021

CONQUERING THE CLOT

Tackling Thrombosis with Technology and Tenacity COVID-19 AT TEMPLE: STORIES UNMASKED

SEPSIS: INSIGHTS, INNOVATIONS

AGENDA Temple Health Magazine

EDITOR Giselle Zayon [email protected] Health Magazine DESIGN & ART DIRECTION B&G Design Studios

WRITERS & CONTRIBUTORS TKarenemple Brooks HealthMagazine Christopher Guadagnino Meredith Mann Jennifer Reardon Andrew Smith Jeremy Walter

BUSINESS MANAGER Younndia Rush

ADMINISTRATION Christopher Guadagnino, PhD Director, Communications Anne Carlin Practical Wisdom Director, Alumni Relations CONTACT US n the spring of 2020, when the City of Philadelphia needed a large indoor Office of Communications space to convert to a field hospital during the COVID-19 pandemic,a ny 3509 N. Broad Street Philadelphia, PA 19140 number of complexes in town could have sufficed — but Temple was the 215-707-4839 only organization to answer that call, lending the City its 340,000- square-foot Liacouras Center (page 18). TempleHealth.org IIn 2017, a Temple physician named Riyaz Bashir, MD, was frustrated. Not a 1-800-TEMPLEMED single catheter on the market could do what he needed a catheter to do, so he Lewis Katz School of Medicine Temple University Hospital designed one himself. Now the unique tool — designed to instantly restore blood Temple University Hospital flow through blood clots— is poised for worldwide use (pages 12 and 44). There’s Episcopal Campus Temple University Hospital been lots of practical Temple thinking about blood clots: the namesake of the Jeanes Campus Temple University Hospital university’s Thrombosis Research Center — Sol Sherry, MD (1916-1993) — Northeastern Campus basically invented the field of using enzymes to melt clots (pages 12 and 46). Fox Chase Cancer Center Fox Chase Cancer Center Another field, colorectal surgery (page 32), owes much about its development to at Buckingham another wise and sensible Temple doc: Harry Bacon, MD ’25 (1900-1981). Fox Chase Cancer Center Medical Group Examples abound. Temple Health Oaks Practical wisdom — a Temple trademark — has made its mark on many fields. Temple Health Center City Even the actual fields of Valley Forge National Park. When the 3,500-acre tract was Temple Health Elkins Park Temple Health Ft. Washington nearly sold for development in 1970, a Temple alumnus named Kenneth Gordon, Temple ReadyCare MD ’48 (1924-2005), mounted the campaign to save it (page 53). Temple Physicians, Inc. Temple Faculty Practice Plan Were these people seeking fortune and fame? No. They simply saw what needed Temple Transport Team

to be done and did it. Temple Health refers to the health, education, and research activities carried out by the affiliates of Temple University Health System, Inc. (TUHS), and the Lewis Katz School of Medicine at Temple University. TUHS neither provides nor controls the provision of health care. All health care is provided by its member organizations or independent health care providers affiliated with TUHS member organizations. Each TUHS member organization is owned and operated pursuant to its governing documents. It is the policy of Temple Health that there shall be no exclusion from, or participation in, and no one denied the benefits of, the delivery of quality medical care on the basis of race, ethnicity, religion, sexual orientation, gender, gender identity/ expression, disability, age, ancestry, color, Giselle H. Zayon national origin, physical ability, level of

JOSEPH V. LABOLILTO V. JOSEPH Editor education, or source of payment.

WINTER 2021 | TEMPLE HEALTH MAGAZINE | 1 18 WINTER 2021 CONTENTS

FEATURES 12 Conquering the Clot Tackling Thrombosis with Technology and Tenacity BY GISELLE ZAYON 18 Behind the Mask: COVID-19 at Temple Stories Behind the Story BY MICHAEL VITEZ AND GISELLE ZAYON 26 Slaying Sepsis Insights and Innovations to Tame a Formidable Threat BY KAREN BROOKS 32 They Called Him “The Boss”: Harry Bacon, MD BY HOWARD ROSS, MD, FASCRS

DEPARTMENTS

36 Inside Story The Writing of Students & Staff

40 Quest Mary Barbe, PhD: Repetitive Strain Injury

42 Change Agent Oneida Arosarena, MD, FACS: 26 Faculty Diversity and Inclusion

44 Tools of the Trade IN EVERY ISSUE The BASHIR™ Endovascular Catheter 1 Agenda 46 Timeline Editor’s Note Titan of Medicine: Sol Sherry, MD, MACP 4 Currents 52 So Noted News Roundup Quotes & Quips 48 Impact 53 Artful Ending Alumni Leaders & Philanthropy

OPPOSITE: ED CUNICELLI; TOP RIGHT: YUKO SHIMIZU; BOTTOM RIGHT: DARIA KIRPACH DARIA RIGHT: BOTTOM SHIMIZU; YUKO RIGHT: TOP ED CUNICELLI; OPPOSITE: ON THE COVER: Blood clots take a huge toll on public health. Photo illustration by MMJ Studio.

WINTER 2021 | TEMPLE HEALTH MAGAZINE | 3 EDUCATION & ENGAGEMENT RESEARCH & CLINICAL CURRENTS APPOINTMENTS & ACCOLADES CURRENTS

Teen Vaping

ithin just months of its initial recognition in the summer of 2019, more than 2,700 cases (including 60 deaths) of E-cigarette or vaping product use-associatedW lung injury (EVALI) had already been reported to the Centers for Disease Control and Prevention. And nearly 80 percent of the patients were under the age of 35. “The surge in youth vaping is alarming,” says Jamie Garfield, MD, Associate Professor of Thoracic Medicine and Surgery at Temple. Between 2017 and 2019, the percentage of high school students who reported using E-cigarettes more than doubled (from 11.7 to 27.5 percent). And it more than tripled among middle school students (from 3.3 to 10.5 percent). At the request of the Pennsylvania Department of Health, Garfield, who is also a spokesperson for the American Lung Association, developed a vaping education outreach program for Philadelphia-area schools — and recruited Temple medical student volunteers to help. “Medical students are excellent ambassadors to deliver this message since they are closer in age to our audience,” Garfield says. “A lot can be lost when information is presented to teens by older authority figures.”

4 | TEMPLE HEALTH MAGAZINE | WINTER 2021 Photograph by CLINT BLOWERS Lay off the Brakes Researchers at the Lewis Katz School of Medicine and Fox Chase Cancer Center have shown, for the first time, that a molecule called EGR4 — known mainly for its role in male fertility — serves as a critical brake on immune system activation. The study, published online in EMBO Reports, shows that taking EGR4 away — effectively releasing the brake — promotes the activation of killer T cells, which infiltrate and attack tumors, thereby boosting anticancer immunity. This strategy could open the door to a new mode of anticancer therapy. The research was led by Jonathan Soboloff, PhD, Professor of Medical Genetics and Molecular Biochemistry at Temple, and Dietmar J. Kappes, PhD, Professor of Blood Cell Development and Cancer at Fox Chase Cancer Center, and was supported by the National Institutes of Health.

$12 Million for Heart Research TEMPLE HEALTH MADE our Temple research programs avenues,” says principal investigator Walter J. focused on molecular mechanisms Koch, PhD, FAHA, the W.W. Smith Endowed of heart injury and repair are now Chair in Cardiovascular Medicine and Director FORBES’ supported by a $12 million Program of the Center for Translational Medicine. BEST Project Grant (PPG) from the This is the Center for Translational Medicine’s FNational Heart, Lung, and Blood Institute. second PPG — prestigious federal grants awarded EMPLOYERS One relates to the role of G protein-coupled to pre-eminent research groups with track re- IN receptor kinases in heart function and disease; cords of significant scientific impact. Two honors PENNSYLVANIA another on the influence of gender on bone given for similar reasons were likewise recently marrow stem cells in heart-tissue repair; the bestowed on Koch himself: the 2020 Research LIST FOR THE third on cardiorenal syndrome; and the fourth Achievement Award of the International Society SECOND YEAR on mitochondrial calcium exchange to reduce for Heart Research and the 2020 Distinguished IN A ROW tissue injury associated with heart attack. Achievement Award of the American Heart

RAUL ARIAS RAUL “All four aim to identify new therapeutic Association Basic Sciences Council.

WINTER 2021 | TEMPLE HEALTH MAGAZINE | 5 CURRENTS

Neuron Chink in the Armor Regeneration New research at Temple iofilms are dense communities alongside lower-dose antibiotics or antimicrobials shows that when present of harmful bacteria that grow on to safely eradicate biofilms before bacteria enter above its usual level, a tissues and implanted medical the circulation where they could lead to deadly molecule in the body called devices. sepsis infection.” Lin28 stimulated long-dis- According to Çagla Tükel, As reported in Nature Communications, tance axon regeneration BPhD, Associate Professor of Microbiology and 3H3 is a first-of-its-kind therapeutic molecule in laboratory models of Immunology at Temple, “Biofilms are notori- that was isolated by Scott Dessain, MD, of the spinal cord and optic ously difficult to eradicate, because they secrete Lankenau Institute for Medical Research, nerve injury. a tough protein called curli, which protects which supported the study, along with the NIH. Shuxin Li, MD, PhD, Pro- them like a shield.” In other biofilms research, Roberto fessor of Anatomy and Cell But Tükel’s team has made a breakthrough Caricchio, MD, Chief of Rheumatology, along Biology, based in the Shriners — literally — with an antibody called 3H3. with Tükel and Stefania Gallucci, MD, of the Hospitals Pediatric Research It creates chinks in the curli armor — letting Department of Microbiology and Immunology, Center at Temple, was antibiotics flow in. was the first to show that biofilms in the uri- senior investigator on the “We are very excited about 3H3,” Tukel says. nary tract can trigger autoimmune flareups in study, which was published “There is great need for an immunotherapy to use lupus patients (Arthritis & Rheumatology). online in Molecular Therapy. “Our findings show Lin28 as a promising therapeutic target for central nervous system injuries. This could be very significant clinically, since there currently are no regenerative treatments for spinal cord injury or optic nerve injury,” says Li. Other scientists in Temple’s Department of Anatomy and Cell Biology participated in the study, along with researchers at Johns Hopkins University School of Medicine. The study was supported in part by the NIH and the Shriners Research Foundation.

Temple Health CEO Honored Michael A. Young, MHA, FACHE, President and CEO of Temple University Health System, has been named one of Becker’s Hospital Review’s “100 Academic Medical Center CEOs to Know.” He was also honored for exemplary leadership, listed among the Philadelphia Business Journal’s “Most

Admired CEOs,” 2020. RICHARD MIA

6 | TEMPLE HEALTH MAGAZINE | WINTER 2021 AIDS Cure: Closer Yet On November 27, 2020, Nature Communications published a major research milestone in the battle against HIV and AIDS: success in using CRISPR gene-editing technology to remove SIV, a virus closely related to HIV (the cause of AIDS), from the genomes of non-human primates. Human subjects will be the focus of the next phase of the research. Kamel Khalili, PhD, Chair of Temple’s Department of Neuroscience, and Tricia Burdo, PhD, Associate Chair of Education in the Depart- ment of Neuroscience, led the ground-breaking research, part of a long-term quest that continues to move ever closer to a cure for HIV infection, which affects more than 36 million people worldwide. Collaborators on this NIH-supported research include researchers from Spray-On Skin™ Tulane University School of Medicine, the Texas emple is using a new technology to treat the size of a credit card can be used to treat a Biomedical Research patients with acute thermal second- and wound up to 80 times larger, and the entire Institute, and the Univer- Tthird-degree burns: the RECELL® System, process can take as little as 30 minutes. sity of North Texas Health a Spray-On Skin™ Cells treatment, which was “This technology can reduce pain and scar- Science Center, along with approved for use in adults by the FDA last year. ring, improve joint mobility, speed healing, Jennifer Doudna, PhD, of The RECELL® System, manufactured by and produce better long-term cosmetic results the University of California, AVITA Medical, requires far less donor skin compared to traditional skin grafting,” says who, with Emmanuelle than traditional grafting to achieve healing of Lisa Rae, MD, FACS, Director of the Temple Charpentier, PhD, won the burn wounds — and in less time. A skin sample Burn Center. 2020 Nobel Prize in Chem- istry for developing the CRISPR gene-editing system.

Editor’s Note: Khalili, The Philadelphia Award Goes to Goldberg Burdo, and another Temple In recognition of her original, nationally acclaimed efforts to curb gun violence in Philadelphia, scientist hold equity in Amy Goldberg, MD, FACS, Temple Health’s Surgeon-in-Chief, was recently honored with a Excision Biotherapeutics, Philadelphia Award — a coveted accolade recognizing “extraordinary service to the Philadelphia which licensed the viral community.” The homicide mortality rate in Temple’s service area is 700 percent higher than the gene-editing technology national rate — making Goldberg’s work imperative. A Temple trauma surgeon for 30 years, from Temple University. Goldberg knows “the catastrophic damage a single bullet can inflict on an entire community. Temple also holds equity in I’m honored to see Temple recognized for these efforts,” she says.

ANNA GODEASSI ANNA Excision Biotherapeutics.

WINTER 2021 | TEMPLE HEALTH MAGAZINE | 7 CURRENTS Honored

Mary Abood, PhD, Professor, Anatomy and Cell Biology, made Eric Gokcen, MD, Associate Professor of Orthopaedic Surgery The Cannabis Scientist’s inaugural “Power List,” recognizing the and Sports Medicine, received the Pennsylvania Medical Society’s nation’s most influential scientists in cannabis research. 2020 Physician Award for International Voluntary Service.

Richard Bleicher, MD, FACS, is winner of the Susan G. Komen® Erica Golemis, PhD, Deputy Chief Science Officer at Fox Chase, Philadelphia 2020 Jamie Brooke Lieberman Remembrance has been named a Fellow of the American Association for the Award for his work in the breast cancer community. Bleicher Advancement of Science. leads the Breast Cancer Program at Fox Chase. Sergei Grivennikov, PhD, Associate Professor in the Cancer Denise Connolly, PhD, Associate Professor in the Molecular Prevention and Control Program at Fox Chase, was recently Therapeutics Program at Fox Chase, is winner of the 2020 named one of the world’s most highly cited researchers, accord- Sandy Rollman Ovarian Cancer Foundation’s Teal Trailblazer ing to the Web of Science Group. Award. Elizabeth Plimack, MD, MS, Chief of Genitourinary Medical Deborah L. Crabbe, MD, FACC, FAHA, Professor of Oncology at Fox Chase, has been elected to the American Medicine, has been selected for the American Society of Clinical Oncology Board of Directors. Heart Association’s 2021 Edward S. Cooper Award for her dedication to eradicating Howard Ross, MD, FACS, FASCRS, Chief of the Division of heart disease in women. Colon and Rectal Surgery at Temple, is President of the Pennsylvania Society of Colon and Rectal Surgeons. Edna Cukierman, PhD, Co-Director of the Marvin & Concetta Greenberg Maura Sammon, MD, Assistant Professor of Clinical Pancreatic Cancer Institute, has Emergency Medicine, has been named Medical been named a Fellow of the American Director of Global Response Management, which Gastroenterological Association. provides medical care at Matamoros, the largest refugee camp along the U.S.-Mexico border. Jeffrey Farma, MD, FACS, Chief of General Surgery at Fox Chase, has been admit- Christoph Seeger, PhD, Professor at Fox Chase, recently ted to the American College received the Hepatitis B Foundation’s Baruch S. of Surgeons Academy Blumberg Prize for excellence in hepatitis B of Master Surgeon research, the Foundation’s highest honor. Educators. Mark Sobczak, MD, FACR, Clinical Thomas Fekete, Director of Radiation Oncology at MD, MACP, Chair Fox Chase, has been named a Fellow of Medicine, has of the American College of Radiology. won the 2020 He was one of only eight radiation Laureate Award oncologists in the nation so honored of the American in 2019. College of Physicians Delana Wardlaw, MD, a family Southeastern practice clinician with Temple Pennsylvania Physicians, Inc., was named 2020 Chapter. Family Physician of the Year by the Pennsylvania Academy of Family Glenn S. Gerhard, Physicians. MD, Chair of Medical Genetics, has received the National Academy of Medicine’s 2020 Edna Cukierman, PhD Healthy Longevity

Catalyst Award. LENTON COLIN

8 | TEMPLE HEALTH MAGAZINE | WINTER 2021 JOEY GUIDONE a majormilestone,” hesays. To discover anew pattern is ular pattern, anew pattern. pathogen-associated molec now we know thatitfollows a Z-RNA for decades —and tists have beenlookingfor says.Balachandran “Scien system to thevirus,” cell andalerts theimmune button thatkillstheinfected then pushes anautodestruct senses theforeign Z-RNA, virus asitreplicates. ZBP1 virus. RNA produced by influenza “sees” Z-RNA, anew form of how,” Balachandran says. lung cells —butdidnotknow presence of influenza virusin called ZBP1 detects the research, publishedin program, lead authorof the Development andFunction Professor intheBloodCell Balachandran, PhD of fields,” says implications for avariety The findings “have exciting destroys infected cells. influenza virusand rapidly mechanism thatdetects the uncovered afundamental Fox Chase researchers have Findings Milestone FOR PATIENT SAFETY “Z-RNA ismadeby theflu It turnsoutthat ZBP1 “We knew thataprotein LEAPFROG GRADED ALL3 TEMPLE “A” CAMPUSES HOSPITAL Siddharth Siddharth ,

Cell

. - - for HIV-AID cutaneous T-cell lymphoma. Zolinza iscurrently approved fortreating collaboration withtheUniversity ofColorado. Research, seniorinvestigator on thestudy, a PhD, FAHA, SeniorAssociate Deanfor suffer from theproblem,” says Steven Houser, therapies forHFpEF, althoughmany people to pump. HFpEF symptoms, improving theheart’s ability in laboratorystudies thedrug, As reported in with preserved ejectionfraction (HFpEF). mon formofheartfailure calledheartfailure already onthemarket. identified promising new usesfordrugsthatare Old Drug,New Purpose A Another teamusedadrugcurrently approved “There are currently noFDA-approved One teamusedacancerdrugtotreat acom

Two research teamsatTemple have AIDS drugtotreat other viraldiseases? cancer drugtotreat heartfailure? An S totreat Zikainfection.InAIDS, Science Translational Medicine Z olinza, reversed

- , flaviviral diseases West Nilefever, Ebola,andhepatitisC for thevirusesthatcausedengue,yellow fever, lication aswell laboratory studies itsuppressed Zikaviralrep tion. Asreported in rilpivirine works by suppressing viralreplica American Heart Association. Defense oftheOffice Naval Research, and the funded inpartby theNIH,Departmentof contributed totheheartstudy, whichwas The Medical University ofGraz(Austria) Senses Center, andCornellUniversity. and Technology, theNIH,Monell Chemical NIH the U.S. Army Research Laboratory, andthe supported by the National ScienceFoundation, Director oftheCenterforNeurovirology. Chair oftheDepartmentNeuroscience and Khalili, PhD, aseniorinvestigator onthestudy, thousands ofdeathseachyear,” says Kamel WINTER 2021 Collaborators onthevirusstudy — included Temple’s ofScience College

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TEMPLE HEALTH MAGAZINE “andislikely todothe same — Molecular Therapy whichcouldhelpprevent — which was — , in all

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9 CURRENTS

A Toxic Partners of Heart Mystery Solved emple and the Guthrie Cardiac Transplant team offers the most advanced Diabetes medications called and Vascular Center, a nationally mechanical circulatory support solutions avail- dual PPα/γ agonists are recognized program with 14 able — including a transplant program with one effective in treating two locations in north central of the fastest “list-to-transplant” rates in the major complications of the Pennsylvania and upstate New York, U.S. and the region’s best one-year survival rate. disease: excess lipids and Thave developed an affiliation that gives Guthrie The team has performed well over 1,000 heart excess glucose in the blood. patients streamlined access to Temple’s heart transplants. It is highly experienced in complex But they can also be toxic transplant and advanced heart-failure services. dual transplants as well (heart-lung, heart- to the heart. No one knew “We’ve created a unified approach to the care kidney, heart-liver, and heart-kidney-pancreas). why until Temple scientists of heart-failure patients, with defined patient “We are also home to a robust research solved the mystery. pathways between Guthrie and Temple,” says program that is pioneering methods to improve “We discovered that these Michael Young, MHA, FACHE, President and patient outcomes,” Young says. drugs negatively impact CEO of Temple University Hospital and Health In 2020, Guthrie was named one of the na- mitochondria, the energy System. tion’s Top 50 Cardiovascular Hospitals by IBM factories of the cell,” One of the most experienced in the world, Watson Health™. It’s the 11th time Guthrie has says senior investigator Temple’s Advanced Heart Failure and received the distinguished honor. Konstantinos Drosatos, PhD, Associate Professor of Pharmacology in the Centers for Translational Medicine, Metabolic Disease Research, and Alzheimer’s Research. “Now that we have a much clearer idea of how heart toxicity arises from treatment with dual PPα/γ agonists, we can more effectively guide the development of future drugs,” Drosatos says. The research, published in JCI Insight, was supported in part by the National Institutes of Health and the W.W. Smith Charitable Trust.

TEMPLE IS PENNSYLVANIA’S ST 1 TO PERFORM A “BREATHING LUNG” TRANSPLANT USING THE OCS LUNG™ DARIA KIRPACH DARIA

10 | TEMPLE HEALTH MAGAZINE | WINTER 2021 Promoted and Appointed

Nicholas Barcellona has been named Executive Vice Ten Chairs President and Chief Financial Officer of Temple University Health System. Ten faculty leaders have been honored with endowed chair appointments: Deborah Cancilla has joined Temple Health as Senior Vice President of Data Strategy and Chief Hossein Borghaei, DO, MS, Chief of Thoracic Information Officer. Medical Oncology, Fox Chase: The Gloria and Edmund M. Dunn Chair in Thoracic Roberto Caricchio, MD, FACR, has been named Oncology. Chief of Rheumatology at Temple. Margie Clapper, PhD, Deputy Scientific Heather Clauss, MD, has been named Senior Director, Fox Chase: The Samuel M.V. Associate Dean of Faculty Affairs at the Hamilton Chair in Cancer Prevention. Lewis Katz School of Medicine. Gary Cohen, MD, FSIR, Chair of Radiology, Amir Emamifar, PharmD, MBA, has Temple Health: The Herbert M. Stauffer Chair been named Chief Pharmacy Officer in Diagnostic Imaging. for Temple Health. Thomas Fekete, MD, MACP, Chair of Medicine: Henry Chi Hang Fung, MD, FACP, The Thomas Durant Chair in Medicine. FRCPE, has been named Chair of the Department of Bone Marrow Transplant Erica Golemis, PhD, Deputy Chief Science and Cellular Therapies at Fox Chase. Officer, Fox Chase: The William Wikoff Smith Chair in Cancer Research. Michael Hall, MD, MS, has been named Chair of the Department of Clinical Enrique Hernandez, MD, FACOG, FACS, Genetics at Fox Chase. Chair of Obstetrics/Gynecology and Reproductive Sciences: The J. Robert Willson Claire Raab, MD, has been promoted to Senior Chair in Obstetrics and Gynecology. Vice President and Chief Clinical Officer for Temple University Hospital. Karen Lin, MD, MPH, FACP, DABMA, DABIHM, Section Chief, General Internal Medicine: The Abhi Rastogi, MBA, MIS, has been promoted to Abraham Roth Chair in Preventative Medicine. Executive Vice President and Chief Operating Officer of Temple University Hospital. Henry Parkman, MD, FACG, Professor of Medicine, Section of Gastroenterology: The Stanley H. Tony Reed, MD, MBA, CPE, has been promoted to Lorber Research Endowment Fund and Chair in Executive Vice President and Chief Medical Officer Gastroenterology. of Temple Health. Mariusz Wasik, MD, Chair of Pathology, Fox Chase: Doug Tilley, PhD, FAHA, has been named Assistant The Donald E. and Shirley C. Morel, Stanley and Dean of Faculty Affairs at Temple’s Lewis Katz Stella Bayster Chair in Molecular Diagnostics. School of Medicine. Johnathan Whetstine, PhD, Program Leader, Angelo Venditti, DNP, MBA, RN, FACHE, NEA-BC, has Epigenetics, Fox Chase: The Jack Schultz Chair in been named Chief Nursing Executive for Temple Basic Science. Health.

Sam S. H. Wu, MD, MA, MPH, MBA, has been named Chair Heather Clauss, MD of Physical Medicine and Rehabilitation and Professor of

JOSEPH V. LABOLITO V. JOSEPH Clinical Physical Medicine and Rehabilitation at Temple.

WINTER 2021 | TEMPLE HEALTH MAGAZINE | 11 Tackling Thrombosis with Technology and Tenacity

Conquering the

lood clots as big as carrots, roots and all, nearly killed Ted Exley and Michael Fischbach. Exley’s saga started with a terrible fall in an icy park- B ing lot. He spent a week in the ICU with skull fractures and bleeding in his brain, but was eventually transferred to a rehabilitation center. He was doing well, all considered — until the night he suddenly had trouble breathing. “Massive clots were found in Dad’s lungs — so large, the physicians were surprised he was still alive. We were told he’d have the best chance of survival at Temple,” Exley’s daughter Ellyn recalls. By the time he got there — transferred from another tertiary care center in the region — he was in heart and respiratory failure. Parth Rali, MD, Assistant Professor of Thoracic Medicine and Surgery, remembers “looking at a 100 percent chance of mortality for Mr. Exley if the clots were not removed right away. The problem was, we couldn’t use clot-busting drugs because they could increase bleeding in his brain. And he wasn’t strong enough for open surgery.”

By GISELLE ZAYON Photo illustrations by MMJ STUDIO

12 | TEMPLE HEALTH MAGAZINE | WINTER 2021

The solution was percutaneous embolectomy, a procedure patient’s blood is then rewarmed, and the heart and lungs are performed with the Inari FlowTriever® — a device designed to returned to normal function. Fischbach came through it well. remove clots exactly like Exley’s — large “central” clots in the Although PTE is unsurpassed for immediate, complete clot main pulmonary arteries. removal (and Temple’s success rate is fantastic, with a 100 per- The effect was almost immediate. Within hours, Exley was cent survival rate this past year), it’s a risky, complex procedure. awake and breathing more easily. It is not appropriate for everyone with CTEPH. A few days later, he celebrated his 74th birthday in the hospital, “That’s why it’s imperative to have alternatives,” says Riyaz with a party thrown by Temple staff — cake and singing included. Bashir, MD, FACC, Professor of Medicine and Director of As a joke, his family bought him a helmet, warning, “Don’t break Vascular and Endovascular Medicine. For some patients, the your head again.” best approach is balloon pulmonary angioplasty (BPA), an endovascular procedure performed with catheters using X-ray image guidance. LUNG CLOTS: ACUTE OR CHRONIC “BPA is a minimally invasive treatment with a much lower he clots in Exley’s lungs were acute. They formed risk profile,” says Bashir. “Rather than removing the clots, we quickly, posing immediate danger. But clots in inflate small balloons inside the blocked pulmonary blood ves- the lung can be chronic, too, building slowly over sels to widen them. This restores blood flow, decreases pressure T time — like the ones that winded 34-year-old in the lungs, and eases strain on the heart.” Michael Fischbach so badly he could barely tie BPA is performed only by a small handful of medical centers. his shoes. Temple is the second-largest BPA center in the country. The Florida resident’s troubles started “We offer exceptional, high-tech options in 2018 with a clot in the femoral vein of his for patients with life-threatening lung left leg that required emergency surgery. clots,” Forfia says. Then came shortness of breath. A CT scan And experience. A founding member showed clots in his lungs. Blood thinners of the national Pulmonary Embolism helped for a while, but Fischbach was still “You don’t want ‘tissue Response Team (PERT) consortium, developing clots. And one of them caused Temple has treated more than 500 patients a stroke. It was quite a run for an active factor’ and blood to meet, with acute pulmonary embolism (PE) dur- young father who remembers having “a because it sets off a ing the past three years alone. clean bill of health until all this.” “PERTs are rapid response teams, Fischbach was diagnosed with a con- cascade of reactions specialists in multiple disciplines who as- dition called chronic thromboembolic that lead to the semble quickly to expedite diagnosis and pulmonary hypertension (CTEPH), which treatment. With prompt risk evaluation affects about 5,000 Americans every year. formation of a blood and treatment, PE survival rates can be In CTEPH, clots build up in the lung, clot,” Kunapuli says. significantly improved,”says Parth Rali, starting a boatload of trouble. Pulmonary MD, Temple’s PERT Director. blood pressure shoots up to the sky. The “It’s all about attaining excellent heart must strain against resistance to get blood to the lungs — outcomes through comprehensive care — from diagnosis to working so hard it can begin to fail. treatment and follow-up. That’s why physicians from all over “CTEPH is a debilitating, potentially life-threatening the country send us patients like Mr. Fischbach and Mr. Exley,” condition — but help is available,” says pulmonary hyper- Forfia says. tension and CTEPH expert Paul Forfia, MD, Professor of Medicine and Co-Director of the CTEPH Program at Temple, CLOT DIVERSITY a Pulmonary Hypertension Association Center of Excellence and Comprehensive Care Center. hronic or acute. Tiny or giant. Different types, Fischbach’s doctors in Florida knew that only a handful of different locations. Every clot is unique — but hospitals in the nation have the expertise to treat CTEPH — all are threats. They can cause stroke or heart including Temple. So to Philadelphia he went for a thorough C attack, compromise the kidney or liver, imperil evaluation by the team. And on June 21, 2019, he became the limb and life. 200th patient at Temple to undergo a specialized surgery called “There are many different types of clotting disorders — some pulmonary thromboendarterectomy (PTE). involving insufficient clotting, others too much. Thrombosis, The goal of PTE is to surgically remove the clots. It entails clot formation, is a complex process that Temple’s been studying placing the patient on a heart-lung machine to keep the blood for 50 years,” says Satya Kunapuli, PhD, Director of the NIH- circulating, cutting through the sternum to expose the heart supported Sol Sherry Thrombosis Research Center. and lungs, and cooling the blood to 65 degrees. Why cooling? The Center was founded in 1970 by Sol Sherry, MD (1916- To slow the metabolism, protecting the brain while the surgical 1993), who helped introduce the original clot-busting drugs, team puts the patient into circulatory arrest. streptokinase and urokinase, to the world (see page 46). “We periodically turn off the heart-lung machine — halting “We study all things clotting,” says Kunapuli. “Inflammatory movement of the chest — so we can safely open the pulmonary proteins; platelets; plasma coagulation factors; protease inhibi- arteries to clear them of clots and scar tissue,” says Yoshiya tors; and the fibrinolytic, complement, and kinin-forming sys- Toyoda, MD, PhD, Chief of Cardiovascular Surgery. The tems. We also study the vascular system, because clots are made

14 | TEMPLE HEALTH MAGAZINE | WINTER 2021 in partnership between blood and blood vessels.” says Paul Katz, MD, Interim Chair of Neurology and Director of Atherosclerosis, the buildup of cholesterol and calcium Temple’s nationally recognized Comprehensive Stroke Program. plaque within the vessel wall, plays a big role in clot formation. “In stroke, the treatment goal is to dissolve or remove the That’s because these plaques are covered with “caps” that can clot as quickly and safely as possible. The faster blood flow is shear off, with the constant motion of blood around them. Now restored to the affected area of the brain, the lower the chance a substance called “tissue factor,” previously concealed by the of disability and death, and the better the chance for recovery,” cap, is exposed to the blood. “And you don’t want tissue factor Katz says. and blood to meet,” Kunapuli says, “because when they do, it Temple has exceptional expertise in stroke care. It’s one sets off a cascade of reactions that lead to the formation of a of just four Comprehensive Stroke Centers in the greater blood clot.” Philadelphia region. This Joint Commission endorsement goes Clots can form almost anywhere in the body. A clot can even to hospitals that provide the highest level of care for the most form at one point, break away from the vessel wall, and travel complex strokes — with speed, efficiency, and effectiveness. through the bloodstream to lodge in another. “As a Comprehensive Stroke Center, we provide state-of-the-art stroke care 24/7 with advanced neuro-imaging and endovascular neuro-interventional capabilities,” says Katz. “We also emphasize HEADY STUFF stroke prevention — medically and through patient education.” hen a runaway clot lodges in the brain, it’s called If ever a city needed stroke prevention, it’s Philadelphia — cerebral embolism. When a clot develops directly where the stroke rate is 20 times the national average — due to in the brain, it is called cerebral thrombosis. Both so many citizens with unmanaged chronic diseases, difficulty W types cause ischemic strokes, strokes that block accessing health care, poor nutrition, and other factors. blood supply to part of the brain. Against all odds, stroke care at Temple leads to nationally “Ischemic strokes represent about 87 percent of all strokes,” recognized outcomes.

WINTER 2021 | TEMPLE HEALTH MAGAZINE | 15 “In 2020, for the eighth year in a row, Temple earned the American Heart Association/American Stroke Association’s Get With the Guidelines® Gold Plus and Target Stroke Elite Plus Quality Awards. We were also the only hospital in Philadelphia to achieve Target Stroke Elite Plus status,” says Katz, crediting the neurologists, neurosurgeons, nurses, and specialists in emergency medicine, radiology, pharmacy, and laboratory medicine who act fast to characterize strokes and initiate life-saving treatment. “Through our participation in the National Institutes of Health’s Stroke Net clinical trials network, we have access to emerging treatments,” says Katz. “We also manage acute stroke care for neighboring community and rural hospitals through a telestroke/ telemedicine network.” Kadir Erkmen, MD, FAANS, Director of Cerebrovascular Neurosurgery at Temple, is surgical director of the Stroke explains Vladimir Lakhter, DO, Assistant Professor of Medicine. Program. “Many patients who would have been killed by stroke Blood-thinning medications can keep clots from forming, but now walk out of the hospital a couple days later, totally neuro- not everyone can take them. logically intact,” he says. “The sooner we can remove the block- “That’s why we have other ways to treat AFib — including The age and reperfuse the brain — and we’re successful in about 90 WATCHMAN™. It’s a dime-sized device we implant in the heart percent of cases — the better the improvement in functional that keeps clots from developing — and also eliminates the need for outcomes.” patients to take blood-thinning medication,” Lakhter says. What Erkmen is talking about is mechanical thrombectomy. The basic idea is to thread a catheter through an artery in the HEARTY MATTERS groin up to the blocked artery in the brain and grab the clot, restoring blood flow to that area. Several devices designed to hen it comes to clots and the heart, the big do this have been tested and approved within the past decade. kahuna is heart attack (myocardial infarction), In 2014 Erkman led Temple’s participation in a clinical trial a clot impeding or blocking blood supply to affirming the safety and efficacy of ofone the first to gain FDA W heart muscle. approval: The Stentriever®. The most serious heart attacks are called ST Before the advent of mechanical thrombectomy, stroke treat- segment elevation myocardial infarctions (STEMIs). These are ment relied exclusively on clot-busting drugs to reduce block- life-threatening, time-sensitive emergencies requiring immedi- age in the brain. “Now we use both approaches,” says Erkmen, ate diagnosis and treatment. “The goal is prompt restoration who, in addition to operating on patients who’ve already had a of blood flow to the heart, which then improves blood flow stroke, performs stroke prevention procedures to open blocked throughout the whole body,” Lakhter says. or narrowed arteries. One device to do this is the Impella pump®, a tiny, powerful There’s only one type of stroke-prevention surgery Erkmen device delivered to the heart via catheter. Other options include doesn’t do. His colleagues in cardiology manage it, because it’s intra-aortic balloon pump (IABP), the Tandem Heart™, ven- surgery of the heart — for patients with atrial fibrillation (AFib), a tricular assist devices (VADs), and extra corporeal membrane heart rhythm disorder that poses stroke risk. oxygenation (ECMO). “In AFib, blood can pool in a small pocket in the heart called the “New devices and procedures have transformed the treat-

left atrial appendage, forming clots that can travel to the brain,” ment of acute heart attack — and the management of heart LABOLITO V. JOSEPH

16 | TEMPLE HEALTH MAGAZINE | WINTER 2021 Far left, top: Kadir Erkmen, MD, and Paul Katz, MD. Far left, bottom: Vladimir Lakhter, DO. This page: Riyaz Bashir, MD, and the BASHIR™ Endovascular Catheter.

heart attack. It all adds up to a public health impact — and medical challenge — of planetary proportion. “But look at the big picture,” says Tony S. Reed, MD, MBA, CPE, Temple Health’s Executive Vice President and Chief Medical Officer. “We have population health programs that reach patients with risk factors for all these conditions. “We have tools like the EKOS EndoWave Infusion Catheter System®, which uses sound waves to accelerate clot breakdown. We even have tools invented by our own faculty, like the BASHIR™ Endovascular Catheter (page 44). “We have specialized programs for difficult disease as well,” Lakhter says. “New medications, too, like conditions, like post-thrombotic syndrome (PTS), a long-term PCSK9 inhibitors, a new class of drugs to reduce cholesterol.” complication of deep vein thrombosis that affects about half a There are many cholesterol-lowering drugs on the market, but million patients a year. There are only a few centers of excel- PCSK9 inhibitors work in a whole new way. lence in the nation for PTS, and Temple is one of them. “They enable LDL receptors to bind to more LDL — the bad “We have imaging techniques that help us differentiate thick, cholesterol — and clear it from the circula- thin, and ruptured caps in plaque — which tion,” says Michael Autieri, PhD, Director helps us identify patients who will respond to of the Lemole Center for Integrated intravenous thrombolysis versus those who Lymphatics Research at Temple, founded need more aggressive treatment,” Reed says. last year with a major gift from Gerald Robust research programs are also driv- Lemole, MD ’62, a well-known heart sur- Clots create a public ing clinical advancement. “Our scientists geon, and his wife, Emily Jane (page 48). are learning more about thrombosis every Another approach — the goal of many health impact — day — and our clinical studies mean we current therapies — is to promote reverse and medical challenge — can give patients access to emerging tools, cholesterol transport, to move cholesterol techniques, and medications they would from arterial tissue to the liver for clear- of planetary otherwise never have,” says John Daly, ance. “The lymphatic system plays an proportion. But we’re MD ’73, FACS, FRCSI (Hon), FRCSG essential role in the reverse cholesterol (Hon), Interim Dean and Emeritus Dean of transport process,” Autieri says. gaining more Temple’s Lewis Katz School of Medicine. traction every day. “It all comes down to patient benefit. To options. To delivering the right treatment UNDAUNTED to the right patient at the right time — with o get ahead of clots, we must get ahead of athero- full consideration for benefits and risks a patient will experi- sclerosis. Which means getting ahead of diabetes, ence. To multimodal care based on protocols endorsed by the too, because diabetes fast-tracks atherosclerosis NIH, the CDC, and leading specialty associations for safety, T by driving vascular inflammation. Nearly 80 quality, and effectiveness,” Daly says. percent of people with diabetes eventually die Lakhter, one of the younger clinicians in the “clot business” of clot-related causes. at Temple, is motivated, not daunted. “It’s a privilege to be part “Clots, in some form or another, disable and kill thousands of of a distinctive team of professionals delivering complex care Americans every day,” says Eric Choi, MD, FACS, Temple’s Chief of to patients with all categories of clot-related disease, both com- Vascular and Endovascular Surgery. mon and rare,” he says. “Also, hundreds of people with vascular disease undergo foot “We cannot save everyone. But every day, patients with seri- and leg amputations every day. But with revascularization tech- ous strokes and STEMI are walking out of here intact, on their niques and comprehensive care, we have ways to save nearly all of own steam. Ditto for patients with pulmonary embolism and those limbs,” says Choi, co-founding Director of Temple’s Limb other thrombosis-related crises,” he says. “How can you not be Salvage Center. optimistic? How can you not be?” Diabetes. Vascular disease. Obesity. High blood pressure. Deep vein thrombosis. Amputation, stroke, pulmonary embolism, To make an appointment with a Temple physician, call 1-800-TEMPLEMED.

WINTER 2021 | TEMPLE HEALTH MAGAZINE | 17 COVID-19 AT TEMPLE Behind +he Mask “When the pandemic infiltrated Philadelphia, Temple University Hospital was hit harder and faster than any other hospital in the region. But we were ready,” said Michael Young, MHA, FACHE, President and CEO of Temple Health. The pandemic pushed caregivers everywhere close to their emotional and physical breaking points — but it also inspired them to new heights, unmasking what people and places are really made of. “Temple is a stronger, more agile, more capable organization in its wake,” Young said.

By Michael Vitez and Giselle Zayon + Photography by ED CUNICELLI

18 | TEMPLE HEALTH MAGAZINE | WINTER 2021 Behind +he Mask From Creed 2 to COVID-19 Believe In 2018, the Boyer Pavilion of Temple University Hospital was Raab worked with Amy Goldberg, MD, FACS, Chair of Surgery, used as a movie set in the filmCreed 2. Two years later, it was and Shane McDevitt, Vice President of Facilities, to convert the ground zero in a pandemic. building. Gerard Criner, MD ’79, FACP, FACCP, head of the Temple From February through April, the trio walked the floors, Lung Center, had been in frequent contact with his colleagues in figuring out where to put up walls, remove doors, set up nursing Wuhan, China, where the coronavirus pandemic began. Create stations, store equipment. They worked day and night, seven “two hospitals,” they urged: one for COVID-19 patients and one days a week. for non-COVID-19 patients. They said this is the best way to Can’t fit a hospital bed through a doorway? Put a stretcher protect patients and staff. in. No time to rewire the floor for This became Temple’s plan of action. telemetry? Use baby monitors. No call Create a massive isolation ward. The Creed bells? Give patients flip phones prepro- 2 building was ideal because of its separa- grammed to call the nurse’s desk. No tion from other parts of the busy hospital. During the first surge, bathroom? Get commodes. But since it was never designed for such a Temple’s 24/7 “Every single person steps up be- purpose, it required a massive overhaul. yond belief, no questions asked. We Within weeks, an operating room floor COVID hotline make things happen out of the blue. We became an intensive care unit. Outpatient responded to ‘MacGyver’ things, that’s what we’re best exam rooms and staff offices were -con at,” said Felicia Nemick, RN. verted into hospital rooms. The expansive Monitors, air scrubbers, HEPA filters. lobby where Sylvester Stallone had staged 65,000+ Code carts, pharmacy carts, radiology a fight scene was now a hospital ward for calls. equipment. Get them, fast. Everyone COVID-19 patients. pitched in: carpenters, environmental The tsunami that had overwhelmed New services workers, transporters, security York City hospitals was about to hit Philadelphia — and Temple guards, biomedical engineers, infection control specialists, Health was determined to be ready. dietary staff. “There’s an anxiety to an oncoming storm,” said Claire Raab, Every day it seemed Goldberg and Raab would ask McDevitt MD, Chief Clinical Officer at Temple University Hospital. “But to do something more extreme. at least when you’re prepared, you know you can handle it.” “Every day I thought, ‘No way we can do this.’ But out of my mouth was, ‘We’ll do it.’ And when it was done, I thought, ‘I can’t believe we did this,’” McDevitt said. Ultimately, the building was readied for 220 inpatients. “Don’t think something can’t be done. It can,” McDevitt said. Sobering “I’ve worked here 19 years and I’ve seen a lot,” McDevitt added. “But when you see things you’ve never seen in 19 years, it’s sobering.” One day he saw a Temple colleague in one of the COVID ICU beds. “She was my friend. And she died,” McDevitt said. Count Us In Marissa Pietrolungo, RN, a nurse who normally works in the Cardiac Intensive Care Unit, remembers the day she volunteered to work full-time in the COVID-19 Intensive Care Unit. “It was March 28. My manager said to me and another nurse, ‘I don’t know what they’re going to do for tomorrow. They need 14 more nurses.’ She wasn’t asking us to work, but we both said, ‘Tell them to put us on the schedule.’” Foresight At the peak of the surge, mid-April 2020, staff were burning through more than 12,000 surgical masks, 1,500 N95 masks, and 9,000 isolation gowns per day — five to six times the normal rate. “Abhi Rastogi, Chief Operating Officer of the hospital, is the supply chain guy. He’s like a godsend. Way back in January he was preparing for masks and gowns and gloves. He made it so we always had enough,” Goldberg said.

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Sprint Spur Normally, nurses care for one ICU patient, sometimes two. But “To say that you were educated in a crucible of change would be now, to limit exposure to staff, theyare truly all in. It was a full an understatement,” John Daly, MD ’73, Interim Dean and Dean sprint, morning to night. Take vitals, give meds, mop the floor, Emeritus, told the medical school Class of 2020 at their commence- empty trash, deliver food trays and carry ment ceremony, an online event. them away. On Easter Sunday, Rosie Orr, Who knew that Zoom would become RN, worked so hard and long she limped to a tool as critical as a stethoscope? That her car after her shift ended. modes and methods of medical education and medical research would have to be Hug 200+ reinvented practically overnight? Late one afternoon, Pietrolungo had a nursing homes in “World-altering events like this pan- patient who was dying. demic will long be remembered not just “I was hugging her, gently telling her southeastern for the damage they inflict, but also for the she was not alone. And I look up and see Pennsylvania were innovations they spur,” Daly said. the patient in the next bed staring at us. She’s intubated, so she can’t speak, educated and coached Rise but I know she’s thinking ‘Is this my by Temple during In March, the Liacouras Center, Temple fate, too?’” University’s sports and entertainment Pietrolungo wanted to go to her and the first surge. arena, was converted into a field hos- comfort her, but couldn’t. pital, readied to accept patients should “I give the first patient some morphine to settle her, make Philadelphia’s hospitals exceed capacity. Temple medical students her comfortable. When she’s calm, I go over to the second helped with the transformation — working with City, military, and patient and tell her it’s okay. Then go to a third patient, whose various agencies, with speed and high purpose. dialysis alarm is beeping, and take care of her. “We teach teamwork in medical school,” said Larry Kaplan, MD “The first patient died an hour later,” Pietrolungo said. “But ’86, Associate Dean for Interprofessional Education. “but didn’t she didn’t die alone. We’re their family now.” envision our students actually working in a scenario quite like this.”

22 | TEMPLE HEALTH MAGAZINE | WINTER 2021 With personal protective equipment The cleaners, nurses, doctors, cooks, in short supply, the risk of infection too pharmacists, therapists. Quarantine, enormous, and no time for veteran doc- test, wait, hope. So small, so huge, that tors to teach and instruct in a pandemic, Despite poor baseline swab at the back of the nose.” students were not allowed in the hospital. health in Temple’s So they found other ways to contribute. Me Delivered groceries to local families. service area — one of Like everyone else, McDevitt took extra Started a phone-a-friend program to ease America’s poorest urban care not to bring the virus home with the loneliness of quarantined patients. communities — him. “My work shoes don’t come inside. I Did online tutoring for low-income shower as soon as I get home. I wash my school kids. Made 9,000 masks. Temple’s COVID clothes separately.” “It’s been an amazing opportunity mortality rate was Raab has four children at home, ages and we’re happy to see such impactful 9, 7, 5, and 1. She worked 15-hour days at results,” said Kurt Koehler, a fourth-year Temple — then tried to follow home- medical student involved in the mask 5.25%, schooling instructions. She decided project. while New York City’s against asking her parents for help, even though they live nearby. “The biggest Swab was above risk to them would have been me,” Christopher Goodwin, MD, ABFM, is one she said. of the people you call at Temple when you . are an employee and fear you’re sick with 10% Lost COVID-19. He’s an occupational health A man had been found in his house, hug- physician — tasked with caring for Temple workers yet still ging his wife’s corpse. She died from COVID-19. Now he was maintaining an adequate workforce to keep the hospital run- sick, too. He was a teacher. He made his living by talking. “But ning. It’s an impossible position to be in. when I met him, he could barely speak. He lost his place in the “Who to quarantine,” he said, “who to send back to the beast. world,” said Monica Busuioc, MD.

WINTER 2021 | TEMPLE HEALTH MAGAZINE | 23 JOSEPH V. LABOLITO Low neighborhoods. “We see up close how this disease really il- Asked to describe a low moment, Goldberg responded this way: lustrates the social determinants of health — divides right down “You can’t have it. You can’t. You must see the positive. You must racial disparity and socioeconomic lines,” Goodwin said. move forward. You must have a plan, the thing you’re going to do next. The more patients we got, the more organized we got. We Groundswell outran it. We did. We outran it.” Pop star Pink donated a half million dollars. Football player Jullian Taylor made a generous gift. R&B icon Patti Labelle sent Vitriol 3,600 sweet potato pies — to cap off 25,000+ meals donated for At first, COVID-19 was described as flu- or pneumonia-like. But it hospital staff. Nearly 350,000 donated masks came in. Temple’s turned out to be more insidious, complex, Pharmacy school made bucketloads of unpredictable. Some patients experienced hand sanitizer. Medical students deliv- mild to moderate symptoms and recovered. ered more than 8,000 bags of groceries to “You can usually look at someone and say local low-income families. with relative predictability that they may or Every day, staff “Whatever challenges Temple faced, may not make it,” said Duwayne Dixon, RN. burned through we did not face them alone,” said Nina “But we learned that you can’t do that with Weisbord, Chief Advancement Officer. COVID.” People donated more than $3 million Pronto, Temple stepped into the global 13,500+ to Temple’s COVID emergency fund. scramble to find the best treatment for masks and A groundswell of giving. the virus, taking part in 32 clinical treatment trials. Honor “In two of them, we enrolled the first pa- 9,000+ “I had never seen teamwork like this,” tients in the United States. One is a Phase isolation gowns, said Tiffany Denson, RN, a Respiratory 2 study evaluating intravenous treatment Intensive Care Unit nurse who switched with gimsilumab. The other is a Phase I her schedule to work in Boyer every trial using CPI-006, an immunostimula- 5x’s shift. tory monoclonal antibody,” Criner said. the normal rate. “Someone was constantly checking on Temple was part of a COVID-19 you. ‘Are you okay?’ they’d ask. I was amazed vaccine trial, too. The only hospital in by the ways everyone chipped in and helped Pennsylvania selected for the ENSEMBLE trial of an inves- out. It was like we formed this bond and felt thankful — honored — to tigational vaccine made by Janssen Pharmaceuticals. “It’s work together.” an important study because it’s the only vaccine designed to work with one dose rather than two, and because the technol- Yo, Philly ogy used to develop the vaccine candidate has a long safety By August 2020, Temple had administered nearly 40,000 record in vaccines for other diseases,” says Nina Gentile, MD, COVID tests, cared for more than 1,500 outpatients with milder Associate Chair and Professor of Emergency Medicine. cases of the disease, and admitted more than 2,000 patients suffering extreme symptoms. Divide Staff played the Rocky theme song whenever a patient recov- Far from being a great equalizer, the virus was quick to exploit ered and went home. patients with underlying health conditions such as hyperten- Every discharge was a victory. sion, chronic lung disease, cardiovascular disease, and diabetes. Exactly like the population in Temple’s surrounding For more information, visit templehealth.org/2019-novel-coronavirus

WINTER 2021 | TEMPLE HEALTH MAGAZINE | 25 Slaying Sepsis

t started like upper respiratory illnesses he’d had before: nasal congestion, body aches, a low-grade fever. The otherwise healthy 50-year-old man initially dismissed the symptoms, but went to the emergency room when they intensified. He was diagnosed with the flu on Monday. By Friday, he was dead. Technically, influenza didn’t kill him.It was that the flu led to sepsis, a phenomenon in which an infection — often bacterial, sometimes viral or fungal — triggers an out-of-control immune response that ravages healthy tissues and organs in addition to attack- ing the infection itself. While many types of infections that can “turn septic” are preventable, sepsis nevertheless remains the leading cause of death worldwide, killing one out of every five people. That totals 11 million deaths every year, according to a January 2020 study in The Lancet. In the U.S., more than 1.7 million adults develop sepsis annually, and 270,000 die as a result — more than opioid overdoses, breast cancer, and prostate cancer combined. Despite skyrocketing diagnoses, confusion about the disease process, and a dearth of treatments, Temple clinicians and scientists are steadily gaining traction against this formidable threat — reducing mortality rates in Temple’s hospitals and uncovering potential new therapies with promise for better outcomes in the future. “It’s exciting. We’ve created a program that’s saving lives — by educating clinicians, leveraging technology, improving communication, and expanding our knowledge base,” says Tara White, MSN, RN, CIC, CNL, Temple’s Senior Clinical Project Manager. “Because we know how to use all the tools in our toolbox, fewer patients at Temple are dying of sepsis.”

By KAREN BROOKS Illustration by YUKO SHIMIZU

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White, a seasoned acute and critical care nurse with a back- early detection is essential, and treatment needs to start in the ground in infection prevention, joined Temple in late 2018 to emergency department — where the vast majority of Temple’s manage its sepsis program exclusively. She supports and guides sepsis patients enter the hospital. staff caring for patients with potential or actual sepsis diagnoses, “It’s a common misconception that most cases of sepsis spearheads sepsis education, and leads sepsis management pro- start with hospital-acquired infections. Only 15 percent of our tocols. Roles like hers are becoming more common as hospitals sepsis patients develop the condition while in the hospital. recognize the need to get a better handle on the condition. The rest come in as emergencies,” says Mark Meyers, DNP, MBA, RN, NEA-BC, Associate Vice President for Performance RAPID RESPONSE Improvement and Project Management. Meyers says Temple follows the sepsis treatment protocols of he term “sepsis” dates back more than 2,700 the Centers for Medicare and Medicaid Services, which outline years to the ancient Greek poems of Homer, several steps — measuring the patient’s serum lactate levels who used it as a derivative of the verb “sepo,” (which rise during infection), obtaining blood cultures, and meaning “I rot.” administering antibiotics on a precise schedule. The guidelines T Today, we understand the condition as a systemic, require quick thinking and action by members of a multidisci- dysregulated, life-threatening response to infection. plinary team beyond frontline clinicians; last year, U.S. hospi- Inflammation becomes widespread. Blood clots form. Blood tals adhered to them on average only 49 percent of the time. vessels leak. Organs become oxygen-deprived. Once septic Since the risk of sepsis death increases nearly eight percent shock (marked by perilously low blood pressure) commences, with every hour that passes before intervention, Temple’s team the survival rate is 50 percent. Treating sepsis before it reaches doesn’t want to miss a beat. this dire stage presents unique challenges for clinicians. “A patient doesn’t walk into the ER with a sign on their SURE SIGNS forehead announcing, ‘I have sepsis,’ and there’s no test that identifies it,” says Richard Martin, MD, Associate Professor emple’s sepsis mortality ranking is among of Emergency Medicine. “Presentation can be vague. Patients the best. In 2019, only seven U.S. academic might not even have a fever. Many common signs — rapid heart medical centers did better than Temple, rate, shortness of breath, confusion, just feeling terrible — look according to the rankings agency Vizient. like other conditions, and we have to differentiate between T “Temple’s sepsis-slaying work is really paying off,” says those and sepsis.” Tony Reed, MD, Temple Health’s Chief Medical Officer. Initial complaints can stem from seemingly benign issues “Since 2018, we’ve had a significant decrease in sepsis deaths, and — even a minor cut. “But sepsis can come on abruptly and there has been a substantial drop in the number of sepsis cases that catastrophically, striking people you would never expect. I have developed within hospital walls.” remember a 16-year-old who came in feeling sick — and died of If sepsis is so difficult to identify early on, how is Templemaking overwhelming sepsis that night,” Martin says. advances? White and Meyers point to multiple reasons. First, Sepsis requires intensive care involving antibiotics (provided technology has made it easier to detect sepsis. Electronic health the cause is bacterial), fluids, and medications that prevent record systems — like EPIC, used at Temple — can calculate blood pressure from dropping. Ventilators and dialysis come risk by collecting patients’ vital signs and laboratory test results, into play if the condition worsens. Its rapid progression means then issuing an automated warning about patients in danger. But these systems use a “one-size-fits-all” algorithm — and while they provide information about sepsis risk, they don’t tell anyone what to do about it. “Standard predictive models use data from millions of patients, but not all populations are the same. Ours is actually very different from the so-called ‘norm,’” Meyers says. “For example, we have a predominantly hypertensive patient population here. So when EPIC fires off a high blood pressure warning — well, most of our patients are already there on any given day. And when blood pressure goes down to what would be considered normal for most populations — for our patients, that would more likely be hypotensive.” To devise an algorithm that better Konstantinos Drosatos, MSc, suits Temple patients, White — with PhD, FAHA programming support from Associate

Professor of Emergency Medicine LABOLITO V. JOSEPH

28 | TEMPLE HEALTH MAGAZINE | WINTER 2021 steps to take for management of sepsis, severe sepsis, and septic shock. Depending on where a patient’s status falls, the cascade tells the clinical team what to do, and when to do it. “When there are tough moments, we want to be able to say with certainty to a patient’s family, ‘we did everything we could, as fast as we could.’ We want everyone here to be confident in their ability to treat sepsis in the best way possible,” she says.

IMMUNE SYSTEM IN OVERDRIVE espite decades of trying, scientists have not developed a medication that targets the hostile immune response and wards off the organ damage that occurs with sepsis. D Because sepsis is not one identifiable organism or “thing,” therapies must be multifaceted. In the past decade, more than 150 drugs have shown enough promise in laboratory settings — but all have failed in clinical testing in humans, prompting pharmaceutical companies to give up their quests for new treatments for sepsis. Researchers at Temple, however, are not deterred. One of them is Laurie Kilpatrick, PhD, Professor of Physiology, Thrombosis Research, and Translational and Clinical Lung Research. She studies how sepsis harms the lungs. Many sepsis patients develop acute lung injury or respiratory distress syndrome, because during infections, the vascular Tara White, MSN, endothelial system — the barrier controlling the passage of ma- RN, CIC, CNL terials in and out of organs — becomes permeable. This means white blood cells and fluid begin to enter the lungs. At this point, patients often require a ventilator. Wayne Satz, MD — customized a “home-grown” alert system “Trying to understand why in sepsis the immune system that accounts for chronic problems like the unmedicated hyper- reacts the way it does to an infection, why it goes on to cause tension, uncontrolled diabetes, and assorted pulmonary deficits this kind of organ damage, is a fascinating challenge. It’s hard to that persist among patients in North Philadelphia. design therapeutics to impact the immune system without “We built this system based on known health disparities in immunosuppressing a patient,” says Kilpatrick, who is the areas we serve. Our model has nuances President Elect of the Shock Society, a — lab-based, radiology specific, vital sign national group focused on improving care specific,” White says. for victims of trauma, shock, and sepsis. Sepsis alerts go straight to White, who According to Kilpatrick, most failed springs into action, checking a patient’s “ ’ sepsis drugs have targeted single mol- records and heading to the bedside to We ve created a ecules, which is problematic since immune consult with caregivers — to make sure ’ system pathways are redundant — if protocols are followed without delay. program that s you thwart one of them, others will still White credits the electronic alerts with perform the same function. Therefore, expediting sepsis detection but believes saving lives. Fewer she began to zero in on an enzyme called Temple’s sepsis successes are actually Protein Kinase C-delta (PKCδ) because more reflective of the excellent knowledge patients at Temple it represents a “hub” within the immune of the staff. ” system — where several pathways join Reed agrees. “Predictive algorithms have are dying of sepsis, together — becoming activated in response an increasingly important role in health care to inflammation or stress. organizations — but only when organiza- says White. In laboratory models, Kilpatrick tions re-engineer processes and redefine has shown that inhibiting PKCδ helps roles in order to act on information. Temple preserve the integrity of the vascular en- has done that,” he says. dothelia, protecting the lungs by keeping white blood cells out. White says everyone’s learning to identify sepsis, even the White blood cells (neutrophils) have a job. They eat harmful most complicated cases. “We’re not just teaching everyone to bacteria. “But when there is no bacteria to phagocytize, you follow algorithms and check boxes — we’re creating an army of have ‘innocent bystander injury’ or ‘friendly fire.’ Tissue gets independent clinicians with considerable know-how, with tools very damaged,” Kilpatrick explains. “We’re trying to corral the to draw on,” she says. neutrophils without knocking them out altogether, because then One is a visual cascade, a flowchartthat shows exactly what the patient would die from overwhelming infection.”

WINTER 2021 | TEMPLE HEALTH MAGAZINE | 29 Kilpatrick has found that inhibiting PKCδ, in conjunction with for anti-inflammatory drugs to work,” says Drosatos, Associate standard care using antibiotics and fluids, results in septic shock Professor of Pharmacology, who also holds appointments in the survival rates jumping from 50 percent to 90 percent in the labora- Centers for Translational Medicine, Metabolic Disease Research, tory setting. “I am very pleased,” she says. “But will this translate to and Alzheimer’s Disease Research at Temple. patients in the hospital?” Drosatos looks at sepsis in relation to cardiovascular compli- She hopes her collaborative work with Mohammad Kiani, PhD, cations, which factor into most sepsis deaths. The heart muscle, Professor of Mechanical Engineering at Temple, will help answer weakened by systemic inflammation, cannot generate the energy that question. Kiani is an expert in microfluidics, a field involving it needs to contract, resulting in insufficient blood flow and tiny, 3D devices that move liquid through miniature microchan- oxygen delivery to the body. Drosatos and his team have im- nels, some measured in submicrons (for comparison, a human hair proved sepsis survival rates in the lab by blocking the activation is about 100 microns thick). Kiani has engineered a novel microflu- of enzymes such as cJunN-terminal kinase (JNK) and NADPH idic system that Kilpatrick can use in her research. oxidase 2 (NOX2) in the heart, thereby returning cardiac energy “He mimicked the microvascular geography on a device that production to near-normal levels. models the structure and function of microvessels. You can see all “NOX2 drives oxidative stress, creating reactive oxygen species the bifurcations, the different vessel diam- — which target mitochondria, the energy eters, and so on. We can actually grow human producers in cells. When we modified ex- endothelial cells in the vascular channels,” pression of NOX2, we were able to restore Kilpatrick says. cardiac function within just a few hours,” Known as “organs on a chip,” these devices says Drosatos. These findings suggest that offer unique tools for all kinds of research More than 150 drugs NOX2 inhibition could potentially keep a and provide a way to test therapeutics with- sepsis patient’s heart from failing, giving out relying on animals or humans. Kilpatrick for sepsis failed clinical traditional anti-inflammatory treatments can isolate neutrophils from healthy donors time to take effect. and patients with sepsis, put them in the mi- testing, prompting Drosatos and his team have discovered crofluidics device, and watch how they move another way to restore energy produc- through endothelial cells. Then, she can pharmaceutical companies tion in the heart, using LGM2605, a observe whether therapeutics she develops synthetic version of an antioxidant in affect that movement. to give up. Temple, flaxseeds. A rich source of omega-3 fatty “This is exciting. We’re beginning to acids, flaxseeds have proved helpful in have the tools to really look at the vascular however, is not deterred. controlling cholesterol, regulating blood endothelial cells and how the immune cells sugar, and fighting several types of cancer. are interacting with them,” she says. “We are Supporting heart function can now be really positioned to make organ-protective advances here.” added to the list. When Drosatos gave LGM2605 to septic mice, the mitochondria in their hearts worked better, cardiac function BUYING TIME improved — and when the compound was given in conjunction with antibiotics, mortality rates fell. ne might assume anti-inflammatory drugs Blood pressure control is another clinical aim in sepsis treat- have not worked against sepsis because they ment. “When blood pressure becomes uncontrolled, that’s it were inadequately designed, but Konstantinos — the end,” Drosatos says. But new work raises hope. As detailed Drosatos, MSc, PhD, FAHA, believes they just in a recent study published online in JCI Insight, Drosatos identi- O don’t have enough time to do their job. fiedthat a protein secreted by the heart in various types of cardiac “I propose that by stimulating organs’ energy stress drives blood pressure down in sepsis. It’s called B-type production, which shuts down in sepsis, we can buy extra time natriuretic peptide (BNP). And the more BNP, the worse.

• Expected mortality, or the number • Below 1.0, then fewer patients died than Sepsis Rankings of patient deaths the hospital would expected. have during the same time period if In hospitals, patient death rates are it performed identically to other In 2019, Temple’s sepsis mortality index conveyed by what’s called a mortality hospitals for the same population. was 0.88. This statistic puts Temple in the index — a ratio created from two sets of top quartile of academic medical centers numbers pertaining to a group with Therefore, if a hospital’s mortality index is: in the United States for low rates of a particular illness or condition: • More than 1.0, then more patients died sepsis mortality, as ranked by Vizient, the • Observed mortality, or the number of than expected; leading health care performance improve- actual patient deaths in the hospital • Equal to 1.0, then the hospital’s mortal- ment rankings agency. The ranking made over a given time period. ity is equal to what is expected; and Temple 8th best out of 160.

30 | TEMPLE HEALTH MAGAZINE | WINTER 2021 in SIREN, the NIH’s Strategies to Innovate Emergency Care Clinical Trials Network. The network spans institutions across the nation but only has 11 hubs, one of which is Temple. In her role, Gentile heads a regional network of community and academic medical center “spokes” in implementing emergency treatment clinical trials for various conditions, including sepsis. “SIREN has marked Temple as a leader in acute care trials requiring rapid identification of patients to start on protocols very quickly,” she says. Temple investigators participate in several studies for sepsis patients. One study is called CLOVERS, Crystalloid Liberal or Vasopressors Early Resuscitation in Sepsis. Clinicians on the front lines of sepsis care have deliberated on what works better to increase patients’ blood pressure: generous administration of fluids or the use of early vasopressors — medicines that constrict blood vessels. “CLOVERS compares these two methods,” says Gentile, who has joined forces with Nathaniel Marchetti, MD, Director of Temple’s Respiratory Intensive Care Unit, to evaluate how much oxygen sepsis patients need during ventilation. “There’s evidence showing negative effects of hyperoxia, too much oxygen, so we’re looking at tiers of oxygen delivery. We identify patients for the study in the emergency department, consent them, randomize them to a group, and start the study protocol — then Dr. Marchetti and his team take it from there,” she says. “We are highly collaborative, and that makes a differ- Nina Gentile, MD ence in figuring out the best ways to change outcomes.”

BEFORE AND AFTER “But BNP activity can be halted — to stabilize blood pressure and give other medications, such as antibiotics, time to work,” ontinuing to reduce sepsis mortality requires Drosatos explains. “This strategy could be used alongside current efforts in both hospital and laboratory settings, supportive strategies, which attempt to slow or prevent fluid loss to but there’s work to be done off campus, as well. stabilize blood pressure.” Tara White’s next big push is for prehospital Drosatos is working with Nina Gentile, MD, Associate Chair and C care — what happens to patients before they Professor of Emergency Medicine, to explore potential clinical come through Temple’s doors. applications of BNP inhibition to prevent septic shock. One is a Since Temple owns and manages a critical care transport monoclonal antibody that inhibits BNP. operation (called T3), White has access to EMS providers, flight “COVID-19 makes BNP inhibition very timely — because nurses, and patient transporters — and she’s helping them rec- elevated BNP plasma levels are linked with COVID-related ognize sepsis and initiate treatment en route to the emergency sepsis,” Drosatos says. department. COVID has exacerbated prevalence of sepsis worldwide in two “I also work with City first responders,” she says. “Unfortunately, ways. First, of course, the virus itself can spark sepsis by targeting though, nine times out of ten, our penetrating trauma victims — multiple organs and causing systemic inflammation.Second, “The people who have been shot or stabbed — come in via police car, large numbers of people putting off getting medical care out of fear of so prehospital care just doesn’t happen. That can be challenging, acquiring COVID-19 means more patients arrive at the hospital very because penetrating trauma can lead to severe sepsis.” sick with infections that make them prone to sepsis,” Gentile says. That doesn’t mean hope is lost for victims of violence who In addition, Drosatos and Gentile were just awarded a new NIH develop sepsis. White recalls a 24-year-old man who had come grant to study the role of a cardiac stress protein in causing septic into Temple’s trauma bay with gunshot wounds and ultimately hypotension. “We are excited about the opportunity this study went into septic shock. He was discharged from the hospital might give us to discover novel treatments for one of the most after a long stay in the ICU. devastating complications of the disease,” Drosatos says. “To see him smile and get out of bed, and to get this big bear hug from his mom, who was so grateful — it is a gift to be a part of those HUB AND SPOKES moments, and that’s what keeps our team going,” White says. “Sepsis is a very complicated puzzle, but everyone on our team t Temple, scientists reach out to work knows how to pick up their piece and put it in the right place. That’s with clinical teams and vice versa. This is why we have been as successful as we have.” “ translational research. It doesn’t happen everywhere,” Gentile says. Karen Brooks is a Philadelphia-based freelancer who specializes in higher education JOSEPH V. LABOLITO V. JOSEPH A Gentile is lead physician for Temple’s involvement and health care.

WINTER 2021 | TEMPLE HEALTH MAGAZINE | 31 « By HOWARD ROSS, MD, FACS, FASCRS » Illustration by SOPHIE TOULOUSE

32 | TEMPLE HEALTH MAGAZINE | WINTER 2021 Harry E. Bacon, MD, ScD, FACS, FAPS ARRY “TED” BACON, MD, BRAZEN SCD, FACS, FAPS, was a world « » leader in colon and rectal sur- IN 1929, WHEN DR. BACON WAS A “RESIDENT” AT PENN, HE gery, and an example to me approached the Vice Dean and head of proctology with a plan of what can be accomplished to create a regional surgical society focused on diseases of the by one person — at Temple anal canal, rectum, and colon. How many trainees would dare — where he held the posi- approach the boss with a plan to advance his field? tion that I fill today: Chief of Brazen or not, Dr. Bacon was focused on the “big” picture. He Colorectal Surgery. knew that we could decrease the number of patients requiring Dr. Bacon is a descendant, stomas, enhance quality of life for patients, and improve outcomes it’s said, of Sir Francis Bacon in many areas of colon and rectal disease. He believed in standard- (1561–1626), the statesman, izing screening to detect colorectal cancer early. He believed in scientist, and philosopher. documenting findings, assessingresults, and developing critical His father, Augustus Bacon, pathways for the care of patients with colorectal disease. MD (1868-1929), was a surgeon who was Professor of Operative Like his ancestor Sir Francis, Ted Bacon was an empiricist. Surgery at Temple for 22 years. Temple had been teaching colorectal surgery since 1906. But In the 1920s, when Dr. Ted Bacon went to college and medical only about 30 of the nation’s medical schools were teaching it in school at Temple, his ambition and intellect were already 1929 — and that had to change. Dr. Bacon knew that the nation apparent. He was President of the Applegate Obstetrical Society. needed more and better teaching programs. He didn’t have all the He was President of the Hickey Physiology Society. He organized answers personally, but he knew that if colorectal surgeons came school banquets. He edited the school’s very first yearbook, the together, they could re-engineer pretty much everything, through Class of 1925 Skull. clinical conferences, educational programs, teaching, publishing, For training, he conducted a seven-year world tour with mas- research, and goal-setting. ter surgeons at University of Pennsylvania, St. Mark’s Hospital Thanks to Dr. Bacon, the Philadelphia Proctologic Society was (London), the Hospital St. Antoine (Paris), the Polyclinico born in 1932. And based on its success, 18 other regional societ- (Rome), and Allgemeines Krankenhaus (Vienna). All of this ies followed. And he didn’t stop there. He went on to become a predated residencies as we know them today. It also predated principal organizer of other major organizations, including the the recognition of colorectal surgery (or proctology, as it was American Board of Colon and Rectal Surgery — which helped to initially called) as an official specialty. make colorectal surgery an official specialty, complete with board- After learning all he could, Dr. Bacon returned to the U.S. in certification requirements. 1932 and accepted a faculty position at Temple. In 1938, he was At one time or another, Dr. Bacon was president of all the major recruited by the University of Pennsylvania — then in 1942, was colorectal surgical societies. He wrote 15 textbooks, 21 chapters in lured back to Temple again, where he remained Chief of Colon other texts, and nearly 350 articles. He earned honorary member- and Rectal Surgery for the remainder of his 50-year career. ship in the Royal Society of Medicine, held 11 honorary degrees and 69 honorary surgical fellowships, was granted audiences with three popes, and was decorated by the govern- ments of eight countries. In 1957, he became founding and longtime editor of Diseases of the Colon and Rectum — still the leading international journal in the field. « THE BOSS » IN THE SURGICAL WORLD, DR. Bacon is known for perfecting an operation called the “Bacon pull- through,” a procedure he developed in 1939 with W. Wayne Babcock, MD, Chair of Surgery at Temple. This operation — which Dr. Bacon traveled the world to teach — pre- vented patients from having to live with stomas, surgically created Ted Bacon, MD, as pictured in the 1925 openings in the abdomen, to expel medical school yearbook. In addition to waste. By the 1970s, the pull-through making charming pen-and-ink drawings like those at right, he wrote music (and lyrics), operation was the gold standard. and earned a PhD in literature, publishing Indru Khubchandani, MD, MS,

three volumes of poetry. FRCS, FASCRS, FACS (“Dr. K”), was MATERIAL ARCHIVAL SCHOOL MEDICAL

34 | TEMPLE HEALTH MAGAZINE | WINTER 2021 a fellow of Dr. Bacon’s from 1962 to 1965, one of more than 80 surgeons he trained personally. “We called him ‘the Boss,’” Dr. K says. “Everyone did. Except his son, who called him ‘Dr. Bacon.’ In addition to the pull-through operation, Dr. Bacon created a ‘pouch surgery’ for patients with ulcerative colitis. It was the number one surgery for this condition in the world.” According to Dr. K, the Boss wore sunglasses, extravagant suits, and two-toned shoes. He had a chauffeur-driven Cadillac. He was invited to all the best parties. Patients flew in from faraway countries just to see him. “He treated presidents, pre- miers, and movie stars. He was a movie star himself,” Dr. K says. The American College of Colon and Howard Ross, MD, with a Rectal Surgeons named a major portrait of Dr. Bacon over lecture in his honor: The Harry E. this right shoulder. Bacon Oration. It’s delivered at the national congress every year — and Dr. K was the Bacon Orator in 1988. He was also the longtime Director General of an organization things that sometimes he forgot patients’ names or the details Dr. Bacon helped create, the International Society of University of their cases. He was good at hiding it. But Dr. K knew what was Colon and Rectal Surgeons. going on. Was the Boss embarrassed? Was he indicting himself in the HIGH IDEALS piece he contributed to the Journal of the American Medical « » Association in 1963 called “Science is Not Enough”? MUCH HAS CHANGED SINCE DR. BACON’S DEATH IN 1981. “It is shocking to hear a physician speak of the hemorrhage Minimally invasive surgery to treat many colon and rectal in bed 10 or the rectal cancer on Ward B,” Dr. Bacon wrote. “In diseases, performed with laparoscopic or robotic equipment, is this impersonalization lies the seed of loss of compassion and now routine. We know many things about empathy for the infirm.” colorectal disease that were total mysteries Was the Boss lecturing everyone? Yes, in Dr. Bacon’s day. Especially cancer. We himself included. “Let us not permit have identified distinct phenotypes and the compassion and humanity to be brushed major genes involved. We can better predict “Everyone called him aside by the frenzied pace of our time,” he treatment responses. We have immuno- ‘the Boss.’ Except his went on. Dr. Bacon’s prescription? It was therapies and other new treatments. All of time to look at oneself. “Reflect on the full it would delight Dr. Bacon. son, who called him meaning of the inscription on a temple When he was young, he idealized ‘Dr. Bacon.’” of the Greeks: ‘Know thyself.’ If we have medicine’s potential. “In a world torn with lessened our insight into ourselves, it is uncertainties, conflicting ideologies and sure to be reflected in an equally dimin- confusion, the medical profession will serve as a stabilizing ished insight into the patient,” he continued. influence . . . establishing good will and promoting understand- As Dr. K says, the Boss was not perfect — and he knew it. Which ing among all the peoples of the world,” he said in a 1950 article is one tiny reason he was so perfectly amazing. in the American Journal of Surgery. Every specialty has its rock stars. Sir William Arbuthnot Lane By the time Dr. K met him, Dr. Bacon had given up on obtain- (1856-1943) might be the headliner in colorectal surgery. But take ing world peace through medicine, but his demands on fellows a closer look: Ted Bacon’s name is also on the marquee. and residents made his goals abundantly clear: optimize cure rates while maintaining optimal quality of life for patients. “The Boss cared deeply about the impact of surgery and treat- About the Author: An internationally recognized surgical educator, Howard Ross, ment on patients in terms of digestive, sexual, and urologic func- MD, FACS, FASCRS, is Professor and Chief of the Division of Colon and Rectal tion,” Dr. K says. That’s what everything came down to. Doing the Surgery at Temple, where he serves as Program Director of the General Surgery Residency, Professor of Clinical Surgery, Surgical Director of the Digestive Disease best for the patient. Yet Dr. K recalls that on post-op rounds with Center, and Vice Chair for Clinical Affairs. He is President of the Pennsylvania Society

JOSEPH V. LABOLITO V. JOSEPH residents and fellows, the Boss was so preoccupied with so many of Colon and Rectal Surgeons.

WINTER 2021 | TEMPLE HEALTH MAGAZINE | 35 INSIDE STORY

his text back was just two words, “Was Stories of the Human asleep.” I should have known. The next day, worried that we hadn’t heard from him, my mom went to check Side of Medicine in and found him on the floor, clearly having suffered from excessive fluid and “ALONG WITH THE HEALER’S TOUCH, stories are at the blood loss. It was horrible. There was blood and diarrhea everywhere. core of a patient’s relationship with caregivers,” says Michael At first, I couldn’t react like a Vitez, Pulitzer Prize-winning author and Director of Temple daughter, only as a medical student. It was way too painful otherwise. When he University’s Narrative Medicine Program. “Stories like these, died, I had to think of him as if he were a written by faculty, students, and staff at Temple Health, have the patient vignette: “A 63 y/o male diagnosed with esophageal cancer power to heal, inspire, build relationships, and change the world,” presents to the clinic with complaints of Vitez says. pain in his abdomen around his J-tube and severe diarrhea and bleeding.” Okay, so, severe fluid loss . . . that can lead to decreased cardiac output, hypotension, day, every week brought on more hypovolemic shock, and death. Post-Op Weight feeding tube issues and new infections. It wasn’t until a few weeks later that Despite all of these difficulties, he I built up the courage to look through Chart never let anyone know how much he my dad’s phone. His last note was titled For years I have told all my friends that was suffering. “Post-Operation Weight Chart.” From my dad was pretty much Liam Neeson My dad had esophageal resection his release on January 28 up until from the movie Taken. It’s about a girl surgery on January 21, 2019. He was February 4, he’d logged his weight, who travels to Europe with her friends released from the hospital on January every day. and is kidnapped. Her father does 28. He died on February 4, just two In five days, he’d lost 7 pounds, down everything to get his baby girl home safe. weeks after the surgery. to 115 pounds. That was my dad. Here’s the thing. His death was totally After his surgery, he gained back some He would do anything for me. He unnecessary. of the weight he had previously lost. He would send me “Good morning, bunny My parents had been divorced since I was so proud of himself. But, as it turns honey, Daddy loves you!” texts every was three, but my mom helped him out, the feeding directions he was given morning and call me every night just to more than anyone else. But with all of us were not correct — and he quickly lost hear what I learned that day in med living separately, my mom and I didn’t weight again. He didn’t complain. school. He’d cry at birthday and Father’s know that the nurses were only coming Nobody noticed. Day cards. every third day. How could he have not known He didn’t ask for help because he I was studying for an exam. And I something was wrong? Why didn’t he didn’t believe he needed it. On the wasn’t checking on him like I should have the right feeding? Why didn’t he rarest occasion that he did ask, if you have. have a nurse coming more often? Why hesitated an instant, he’d get angry. I The last time I saw my dad, he was didn’t he call me or my mom or 911? think that’s because it was just so hard walking towards me, proud that he was He must’ve been scared. I would’ve for him to ask. on his fourth lap around the step-down been. But it was always just too hard for And then my dad was diagnosed with unit, smiling and joking with the nurses him to ask for help. esophageal cancer. Prior to his diagno- that he was starting bids to be the next It’s hard to admit that I’m angry at sis, he’d lost over 60 pounds. He couldn’t “Bachelor.” my dad, but it’s true. How did he let swallow due to the obstruction in his He sent me a text after he was himself get to this point? Why didn’t he esophagus. After he was diagnosed, he released: “Good morning, bunny honey. just ask for help? I’m also angry at his needed to go through chemo and This exam? Chew it up raw and spit it medical team. They must not have radiation, which could lead to more out. You’re the best! I love you! XOXO.” really known my dad. If they had, they weight loss, so his doctors gave him a After the test, the night of the Super wouldn’t have let him push them away. feeding tube. Bowl, the night before he died, I texted They would have known he was too On top of chemo and radiation each him. My dad was a huge sports fan, and proud to ask for help.

36 | TEMPLE HEALTH MAGAZINE | WINTER 2021 Illustrations by LEONOR GARCIA DEL VALLE But I’m also mad at myself. I members. We can perform the fanciest patients, care for them and follow up should’ve done more. Why didn’t I procedures and provide the best with them. And if our patients aren’t force him to go to the doctor months medications, but that’s not enough. going to advocate for themselves, we beforehand? Medicine is as much an art as it is a must advocate for them. I don’t have all the answers, and that’s science. It’s not just about a patient’s So as I continue to study microbiol- okay. But I do know that I want to make creatinine or glucose levels, it’s also ogy, cardiopulmonology, and the science sure that no one else’s daughter has to about truly understanding your of medicine, I’m also going to learn the ask the questions that I’m asking now. patients. art of medicine. I’ll continue to grieve Sharing this now helps me deal with I want truly to know my patients and about my dad’s death, but I hope I can my own grief. But I also hope sharing ask myself — can I do more to help learn from it, too, and become a better this with all of you, my peers and them? I also want my patients to feel physician because of him. colleagues, can help us learn to become comfortable asking me for help. As — RACHAEL SMITH better doctors, nurses, and family doctors, we have to connect with MD Candidate, 2022

WINTER 2021 | TEMPLE HEALTH MAGAZINE | 37 white coat, we are ready to learn, we are “aged” white coat. Every stain, every The Whitest ready to teach, we are ready to make a scuff, and every accidental pen mark will difference. But we are also ready to forever be linked to a memory. After all, White Coat make mistakes. And that’s okay. This a white coat is not meant to spend its life I keep my white coat white. I’m talking year we are likely to be the most hanging in a locker. Mr. Clean white. Sensodyne White. inexperienced members of the health This coat will travel with me. And no White-on-rice white. New Balance care team. And just as these last two matter how worn it gets, one thing will sneakers on a middle-aged suburban years have flown by, so too will the next never change: this will always be my first dad white. In fact, some classmates two. Regardless of the impending white coat. And regardless of how make fun of me for getting my white challenges, we are ready for what’s next. “un-white” it may get, it will always be coat dry-cleaned, but what can I say? While I doubt I will be able to my favorite. It’s my favorite piece of clothing. maintain my coat’s bleached-white — AZAM HUSAIN Every time we put on that Temple color, there is also pride in wearing an MD Candidate, 2021

38 | TEMPLE HEALTH MAGAZINE | WINTER 2021 found that six out of every 10 doctors overdose-related comas can result in What Does it Mean surveyed were either very or somewhat elevated levels of motor activity due to pessimistic about the future of the the drugs’ effects on the brain stem. to be a Good Doctor medical profession. Contrary to what a hopeful mother A few years ago, I shadowed a Fortunately, however, some might believe, this was not a reflection neurologist at a hospital near my family physicians, like the neurologist I was of consciousness or active motor home in Connecticut. It was a relatively shadowing, take time to know their reflexes. slow day for the doctor, full of chart patients. Because it can be difficult to The doctor delivered her opinion reviews and sifting through brain mentally construct patients’ lives and with patience and kindness. She was images for abnormalities. As she went narratives from the medical lingo of present for the mother. She understood about her paperwork, she shared her their charts, the doctor filled in the that the young man was someone with insights with me, especially when gaps for me that day. She gave life and a family, a life worth living. She saw a something “exciting” popped up. meaning to abridged notes and grieving mother who would soon have I learned what an ischemic stroke apathetic paperwork. She told me to make peace with this tragedy. looked like on a CT scan. I saw what about a young man who was likely Observing their interaction, I could see electronic health records looked like taking his last breaths following a that most of the medical information across an assortment of patients and combined alcohol/cocaine/narcotics the doctor shared flew past the health statuses, annotated by various overdose. And while I was there, she woman’s ears. She knew what she had health care providers. I read what was called to the ICU to examine him seen; she fully believed that her son was doctors considered to be objective for the nth time in as many days. on the cusp of waking up. But the truths about their patients, data points On the elevator ride up, she told me neurologist knew the damage was done. and test results. I read the things that he was an Ivy League college student That day, I saw that the language of mattered to insurance companies and who had been doing careless college evidence-based medicine cannot provided the doctors their paychecks. student things. Her disappointment console human beings facing loss. That I saw a complicated system of documenta- was laced with a hint of sadness. It was the objective medical gaze or micro- tion that put the medical record and humbling to see — especially since I scopic view of the body cannot provide provider reimbursement at the heart of didn’t know what I was walking into comfort or reassurance. That the “patient-centered” care. that day. I wondered what it meant to empathy we are taught to show And as I read phrases like “patient be an overdose patient in a culture rife patient-actors in our clinical skills insists [x]” or “seems convinced of [y]” with overmedicating, over-testing, and courses cannot build trust between real or “comes in frequently, seeking over-charting — none of which offers an doctors and real patients. A scripted attention,” it was as if a person’s own iota of compassion to a patient on the “Oh, I’m sorry to hear that” only goes lived experience was not trustworthy verge of death or a family nearing an so far. enough for science — or at least not irreplaceable loss. In the end, it’s about the impulse of relevant within our fee-for-service She led me to her patient’s room in being human, the vulnerability of being model. There is no place for a patient the ICU. He was no more than a year or ill, and the process of healing, all of to be the first author in their own story, two older than I was at the time. As I which we share in but often forget in the a role reserved for the educated, watched the ventilator help his limp process of becoming “professionals.” objective clinician. body inhale and then exhale, I But that day, I saw what it meant to When no data exist to explain imagined he might have had a bright look beyond a patient’s chart and to particular illnesses — when science has future ahead. I wondered about the deviate from the script of a medical no answers for patients — they are college party that allegedly landed him school doctoring course. I saw a young judged, labeled attention-seekers. in this place. I wondered if he had been man with his own story; a mother in When time is money, it’s easier to view addicted or could’ve been helped. I sorrow, no less a patient in that the patient as hypochondriacal, wondered who he would be leaving moment; and a doctor with oodles of noncompliant, or attention-seeking. behind. I said a silent prayer for him as knowledge standing quietly in While looking through the charts that the doctor examined him, again solidarity with her. The neurologist day, I could almost hear the authors confirming a poor prognosis. reached her hand out and the mother scoff in judgment. Quick footsteps approached. The graciously accepted the comfort, One might be inclined to believe that doctor stepped into the hall to greet her genuine and uncontrived. That, to me, electronic health records bring more patient’s mother. It became clear that is patient-centered care. I’d be curious benefit than harm to health care. But, his mother was just as much in need of to see how an electronic health record in reality, it means patients get the doctor’s warmth and care as he was. or insurance company might capture it significantly less time with doctors and And the neurologist recognized it. I for reimbursement. feel more neglected. It means people listened as the doctor relayed a difficult — KOMAL GULATI are living longer but with more chronic prognosis. I watched the mother clutch MD/MA Candidate, 2023 conditions. It means patient-centered her prayer beads so tightly her knuckles care is being swapped for patient- turned white. “I know he’ll be okay,” Editor’s Note: A version of this essay was centered charts. Little wonder that a the mother argued. She had seen him published in Scientific American on 2018 Physicians Foundation survey move. I remembered learning that March 27, 2020.

WINTER 2021 | TEMPLE HEALTH MAGAZINE | 39 QUEST

Wear, Tear, and Repair

“A condition called telegraphists’ cramp, which are not working. If we can reverse muscle fibrosis, workers could eventually return affected the hand muscles required to operate a to their jobs,” Barbe says.

Morse code machine, was prevalent in the early Last year, in the Journal of Orthopedic 1900s. It was one of the first documented repetitive Research, Barbe reported that pamrevlumab also relieved the irritative, strain injuries,” says Mary F. Barbe, PhD, Professor compressive effects of carpal tunnel syndrome, a common RSI associated with of Anatomy and Cell Biology at Temple. weakness and functional decline.

She’s also found that manual therapy — techniques including massage, stretch- Caused by repeated motion that dam- surgery fails, because you can’t just go in ing, and chiropractic intervention — is ages tissues of the musculoskeletal and pick out all the fibrosis.” helpful. It breaks down fibrotic tissue, and nervous systems, repetitive strain promoting repair and recovery. “Bodies injuries (RSIs) spark persistent pain — RSIs have long been thought to be irre- are amazing things — sometimes we just usually in the neck, shoulders, forearms, versible, but Barbe’s research shows, for need to help them along,” she says. wrists, and hands. “They can be debili- the first time, that it may be possible to tating,” Barbe says. undo the damage caused by fibrosis and Barbe has authored many book chapters restore muscle strength — offering hope and has won numerous teaching and re- RSIs are common among athletes. for people who have been unable to work search honors, including the 2018 research Computer and smartphone overuse due to overuse injury. prize of the International Society for the can cause them, too. But Barbe studies Study of the Lumbar Spine — recogniz- “higher-load, higher-force tasks. Think The findings, published online in 2019 in ing her collaboration with David Klyne, construction workers, nurses moving The FASEB Journal, detail the results she’s PhD, and Paul Hodges, PhD (University patients, or hotel staff lifting mattresses achieved in preventing and reversing RSI- of Queensland, Australia), for findings and ending up with elbow tendinitis or a related fibrosis with a drug called pamrev- regarding contributors to low back pain. rotator cuff problem,” she says. lumab, a compound recently approved by the U.S. Food and Drug Administration Barbe also collaborates with Michael High-force, high-repetition movements for the treatment of Duchenne muscular Ruggieri, PhD, Professor of Anatomy create microinjuries in muscle fibers. dystrophy. Barbe and colleagues, includ- and Cell Biology at Temple, to develop Muscle tissue responds by making small ing Steven Popoff, PhD, the John Franklin techniques to reinnervate the bladder and repairs. But over time, with repetition Huber Chair and Professor of Anatomy urethral sphincters. “Functional rein- of the activity causing the injury, muscle and Cell Biology, found that the drug nervation of the bladder is possible — and tissue becomes replaced with connective can halt — even reverse — the scarring would be a great boon to patients who’ve tissue — weakening muscles and putting process. Pamrevlumab is an antibody that suffered spinal root injury,” she says. pressure on nerves, causing inflamma- inhibits connective tissue growth factor, a tion and pain. “With nerve injury, you protein that contributes to fibrotic disease Barbe’s research has been supported develop hypersensitivity to normally progression. by the National Institutes of Health innocuous stimuli,” Barbe says. for 18 years. A native of Virginia and Pamrevlumab for RSI is a novel applica- North Carolina, she is a fellow of the “A lot of treatments fail. Rest doesn’t work tion. “It’s being fast-tracked by the FDA American Association of Anatomists for everyone. Physical therapy doesn’t for patients with idiopathic pulmonary and the American Society for Bone and work for everyone,” says Barbe, who also fibrosis and kidney fibrosis — but would Mineral Research — and is currently holds an appointment as Professor in the also be a good drug for people with Vice President of Advances in Mineral Department of Physical Therapy. “Even overuse injury whose other treatments Metabolism, an international association.

40 | TEMPLE HEALTH MAGAZINE | WINTER 2021 Photograph by CARDONI Mary F. Barbe, PhD CHANGE AGENT

Oneida Arosarena, MD, FACS ASSOCIATE DEAN, DIVERSITY AND INCLUSION

Diversity is part of accreditation criteria Q: What barriers do minority faculty for medical schools, correct? encounter? A: They tend to feel isolated, not truly part of the larger academic community. Yes. In 2009, the Liaison Committee on Medical They tend to experience more pressure Q to “prove” themselves by serving on Education (LCME) toughened diversity committees, mentoring minority & requirements for accreditation, mandating that students, and other things that do not medical schools enact “policies and practices “count” among the criteria for being promoted. Minority faculty report lower ensuring the gender, racial, cultural, and career satisfaction, and leave academia economic diversity of its students.” The LCME sooner than other faculty. So recruiting is just for openers. If you want people to has called for schools to diversify faculty as well. stay, you must make them feel welcome A and wanted. Q: What can schools do to improve Q: Latinx and African Americans make up and communities. faculty diversity? 31 percent of the U.S. population — but only Many organizations, including medical A: Efforts to enhance faculty diversity 10 percent of its doctors. That said, if schools like Temple, conduct implicit require long-term commitment. For physicians are fair-minded and clinically bias training to help students and faculty starters, we must get more people of excellent, does their race really matter? identify bias that might negatively impact color into the medical profession. Which A: Let’s look at things from the patient patients, families, and colleagues. The means working with children. And if you perspective. When patients receive care trainings can be a real eye-opener. have people of color on your faculty, you from physicians of their own cultural need to keep them by limiting obligations background, communication is Q: Systemic bias is bias that’s baked into a that do not contribute to promotion; enhanced and patients do better. system or process. Is that implicit, too? supporting protected research time; At medical schools, diverse teams are A: Absolutely. For example, imagine setting clear goals; developing mentoring best able to flex, pivot, and adapt as they you’re a faculty recruiter. You approach programs for junior faculty; and teach future generations of physicians the process in a traditional way: getting improving networking and leadership to care for a wide spectrum of patients. leads on candidates from chairs at your opportunities. You need strong institu- The Institute of Medicine endorses school, advertising in major medical tional support — not just dollars, but diversity in the medical profession as a publications. While your school advocacy from faculty leaders, support strategy to improve public health. encourages minority applicants, rarely that affects the climate of the institution. Cultural competence is a gateway to do any apply. Then someone suggests you It’s not just about who gets a seat at the clinical competence. advertise in publications read by table, but whose voice is heard. minority physicians — and try asking Q: Temple and other groups you work faculty of color in your school if they have Q: You are a highly respected head and with, such as the Association of American any candidates to recommend. When you neck surgeon. You do NIH-supported Medical Colleges, endorse implicit bias do these things, you get wonderful research. You teach. You’ve traveled the training. What is implicit bias? minority applicants. Implicitly, systemi- world on surgical missions. What means A: Implicit bias is bias that we don’t cally, the prior approach had been biased most to you? realize we have. And we all have it. It’s toward traditional applicants and away A: Seeing opportunity where once there part of the human legacy, based on the from minority applicants. You just didn’t were obstacles — and openness in minds “norms” we grow up with in our families realize it. and hearts once closed.

42 | TEMPLE HEALTH MAGAZINE | WINTER 2021 Photograph by PETER FREED Oneida Arosarena, MD, FACS TOOLS OF THE TRADE

A New Twist The BASHIR™ Endovascular Catheter

lood clots threaten the The BEC’s magic is its expandable The BEC has even been used with health and lives of 900,000 spiral-shaped “basket,” composed of six success in COVID-19 patients. Americans every year. hollow filaments that do two jobs.First, As detailed in the story on they work like scalpels, fissuring the THE BEC: HOW IT WORKS page 12, there are several clot. Next, they work as catheters, infus- After the patient is sedated, the physi- Bways to treat these circulation-blocking ing clot-dissolving medication through cian inserts the BEC into the blood culprits. One rapidly evolving modality 48 tiny laser-drilled holes. vessel where the clot is located using is catheter-directed therapy (CDT). Bashir had a punch list for design- X-ray guidance over a wire. When its tip “The idea behind CDT is to get ing the device: It must be easy to use. It is in proper position within the clot, the clot-dissolving medication right into must involve minimal procedural risk. physician expands the basket by sliding the blood clot,” says Riyaz Bashir, MD, It must reduce the amount of clot- the red lever on the hand-held control. FACC, RVT, Director of Vascular and dissolving medications needed (thus The basket is 2.3 mm wide when closed Endovascular Medicine at Temple. likewise decreasing the associated risks, and can be expanded up to 45 mm. Conventional CDT usually works for like brain bleeds). It must also shorten As the basket opens, its six fila- clots in smaller blood vessels. patient length of stay, and with it, health ments twist and expand, creating But for clots as big as carrots, its abil- care costs. spiral fissures in the clot, restoring The BEC checks all blood flow. The filaments of the basket these boxes. Bashir are nickel-titanium reinforced nylon designed it in 2015 tubes with 48 laser-drilled holes that Clot-dissolving medication can only with help from an deliver medication, which can be experienced engineer, pulse-sprayed or infused at precisely reach the part of a clot exposed to Nicholas Green. Then controlled rates. blood. Hence Bashir’s inspiration: Temple University When the clot has dissolved and it’s and other investors time to remove the catheter, the physi- to design a catheter that fissures the founded a company cian returns the basket to the closed clot, getting blood to flow in, along called Thrombolex, position using the red lever on the hand- Inc., to manufacture held control. with medication. the BEC and other catheters designed by OTHER UNIQUE CATHETERS ities are limited. “When clots completely Bashir and team. In addition to the BEC, the team obstruct the circulation, medications in In an FDA-approved early feasibil- has designed six other catheters for the blood can only reach the small area ity study, the BEC was shown to be safe specialized functions: The BASHIR™ of the clot exposed to blood flow.The and highly effective for treating acute Endovascular Catheter NX, which interior of the clot remains impervious,” clots in the lungs. In this small study, the creates one channel in a clot; the Bashir explains. outcomes were significantly better than BASHIR™ Endovascular Catheter SB Hence his inspiration: to design a those of standard CDT and/or mechani- (Short Basket); and the BASHIR™ catheter that carves channels within a clot cal approaches to clot removal. Plus Endovascular Catheter line, a — increasing that exposed surface area. “Right now, an FDA-approved series of catheters with two infusion “The other goal with this device is to NIH-funded pivotal study called the pathways, one in the basket and one get the blood to flow into the clot along RESCUE trial is underway. Twenty in the shaft. These come in four sizes: with the natural clot-dissolving chemi- medical centers across the U.S. are The BASHIR™ +10 (cm); +20; +30; and cals in the patient’s own blood,” explains evaluating the BEC for patients with +40. All are easy-to-use tools that can Bashir, inventor of the BASHIR™ large blood clots in the lungs,” Bashir be used quickly and safely in veins and Endovascular Catheter (BEC) . explains. arteries in the limbs, torso, and lungs.

44 | TEMPLE HEALTH MAGAZINE | WINTER 2021 Illustration by BRYAN CHRISTIE BASHIR™ Endovascular Catheter

The BASHIR™ Endovascular Catheter features an expandable basket that carves channels in a clot, enabling blood and medication to flow in. TIMELINE

Titan of Medicine Sol Sherry, MD, MACP (1916-1993) c: 1950 fter school and on week- ends in the 1920s, young Sol Sherry worked in his 90 percent of heart attacks. He reported fibrinolytic system in human blood and parents’ New York grocery on streptokinase for acute myocardial the action of lysing enzymes. store, totaling customers’ infarction at least 25 years before it be- In 1949, he and Tillett became the first purchasesA in his head. He loved math prob- came an established therapy,” says Ronald to use streptokinase to dissolve fibrin- lems and puzzles, the tougher the better. Rubin, MD ’72, Emeritus Professor of ous collections of fluid in patients’ lungs. He certainly picked a challenging career: Hematology at Temple. “Back then, streptokinase was used in thrombosis. The field was practically a Sherry drove the development of a new tissue spaces. It was too impure to be ad- blank slate when he was introduced to it approach to clotting-related pathologies ministered intravenously,” Rao says, “but in the 1940s — but that’s probably what — revolutionizing treatment not just for Sherry helped change that.” captivated him about it in the first place. In the early 1950s, at the Sherry devoted 50 years to developing it to University of Cincinnati, the point of “a clinical payoff,” he said, “so I Sherry and Walter Troll, could feel that my life has been fulfilled.” MD, became the first to use “Everything he embraced turned synthetic substrates and AGAINST THE ODDS to gold. Institutions prosper for plasminogen activators “Thrombosis is a clinical cosmos in its to dissolve clots intra- own right, and Sol Sherry deserves credit years on the energy of great vascularly. Then in 1954, for making it so. He’s the father of throm- when Sherry was Chair of bolytic therapy,” says A. Koneti Rao, MD, leaders like Sol Sherry,” says Medicine at Washington FACP, FHAA, the Sol Sherry Professor University, he became the of Medicine and Co-Director of the Sol Rubin. first to use urokinase to Sherry Thrombosis Research Center at treat pulmonary embolism Temple. myocardial infarction but also for pulmo- and venous thrombosis. After that, things Sherry — who spent the last 20 years nary embolism and deep vein thrombosis, really picked up speed. In 1967, Sherry of his remarkable career at Temple (and common pathologies all over the world. led the famous Urokinase and Urokinase- recruited Rao) — basically created the life- Streptokinase Pulmonary Embolism saving field of clot-busting via the thera- FIRSTS Trials, funded by the National Institutes peutic use of enzymes. “His insights were Sherry met his love/nemesis in 1946 of Health. amazing,” says Rao. “He recognized early when he got his first job, with William “This study was a game-changer,” Rao on that thrombosis was a primary cause of Tillett, MD, at New York University. About says. But what was truly amazing is that myocardial infarction — not a secondary 12 years earlier, Tillett had discovered that Sherry was hugely influential in making or incidental aspect thereof.” beta-hemolytic streptococcal organisms — federal funding available for that study in In the 1950s Sherry proposed that most the bacteria that cause strep throat — can the first place. He’d been leading a cam- heart attacks are caused by a blood clot in induce a proteolytic reaction that breaks paign at the highest echelons of medicine an artery. Few experts believed it until it down blood clots (J. Exp. Med, 1933). This to draw attention to clotting pathology was definitively proven in1980 . “reaction” came to be known as strepto- and the need to intervene. In 1965, as “Dr. Sherry had been right all along — kinase. Foreseeing its immense possibili- part of this effort, Sherry persuaded the

that blood clots in heart vessels caused ties, Sherry was sold. He had to study the National Academy of Sciences to create NYU; ARCHIVES, CHAPELLE MEDICAL AND CLARENCE DE LA LILLIAN COURTESY IMAGE: 1954 CENTER RESEARCH COLLECTIONS SPECIAL LIBRARIES TEMPLE UNIVERSITY IMAGE: 1990

46 | TEMPLE HEALTH MAGAZINE | WINTER 2021 a task force on thrombosis. It did, and center for thrombosis research — one Sherry its first Distinguished Professor. In named Sherry chair. In 1971 (while at of the first to receive NIH funding as a 1984, it appointed him Dean of Temple’s Temple), he founded the American Heart Specialized Center of Research (SCOR) in medical school. In 1986, Sherry estab- Association Council on Thrombosis. He thrombosis. He appointed and recruited lished Temple’s MD-PhD program. In also became a founding organizer and outstanding researchers and faculty, 1987, Temple presented an endowed chair Chair of the International Society of including Alfred Bove, MD, PhD; Andrei in his name (currently held by Rao). And Thrombosis and Hemostasis. Budzynski, MD, PhD; Robert Colman, in 1991, the Thrombosis Research Center “These organizations played a critical MD; H. James Day, MD; Robert Fisher, was renamed in his honor. role in making the medical world aware MD; Holm Holmsen, PhD; Bennett Sherry was never nominated for the of the enormous public health impact of Lorber, MD; Leon Malmud, MD; Victor Nobel Prize that some say he deserved, thrombosis, in rallying for study and fund- Marder, MD; Stefan Niewiarowksy, MD, but many honors came his way from high- ing,” says Rao. PhD; Gwendolyn Stuart, PhD; Peter status organizations like the Texas Heart “That was Dr. Sherry’s genius in a nut- Walsh, MD, PhD — and many more. Institute, the American Heart Institute, shell — seeing the global picture and the “He wasn’t just the father of throm- the American College of Physicians, and molecular details — with clarity to change bolytic therapy; he was our father, and the American College of Cardiology. the world,” Rubin says. we revered him,” says Rubin. “He was an Sherry died at Temple University astute judge of character. He could see Hospital on January 28, 1993. He had THE TEMPLE YEARS what we were good at — and not so good pancreatic cancer. Sherry was recruited to Temple in 1968 at — and directed each of us accordingly. “Sol Sherry was an astounding scientist to chair the Department of Medicine. “He Respecting him like a father also meant of great vision,” says Rao. did so much for medicine and for Temple that every summer when he brought in “Everything he embraced turned to during his 20 years here — including mak- these nine-pound zucchinis he grew in his gold,” Rubin adds. “He was extremely ing Temple’s Internal Medicine residency beloved garden, everybody would have to loyal to Temple, and we were loyal to one of the best in the country,” Rubin says. eat them.” him. Institutions prosper for years on the In 1970, Sherry founded Temple’s In 1983, Temple University named energy of great leaders like Sol Sherry.”

c: 1990

WINTER 2021 | TEMPLE HEALTH MAGAZINE | 47 ALUMNI UPDATES PHILANTHROPY NEWS PARTNERS IN PROGRESS IMPACT Emphatic for Lymphatics Lemole on Lymphatics

Q: How did your interest in lymphatics begin? A: In my early days in Houston, I was puzzled by unexplained poor heart transplant outcomes and suspected lymphatics were somehow involved. So little was known about this system at the time that it was largely overlooked. Then, serendipitously, when I returned to Temple as Chief of Cardiovascular Surgery in 1969, I met two scientists who were studying lymphatics and immunology. We started looking into how the surgical team could handle the lymphatic system during transplant surgery. Temple was one of the first institu- ith a $5 million gift, Gerald M. Lemole, MD tions to appreciate the significance of lymphatics research. ’62, and his wife, Emily Jane, have established For the most part, scientists tend to approach it tangentially as the Lemole Center for Integrated Lymphatics they study other things. Temple recognizes it as the integral Research at the Lewis Katz School of system that it is. Medicine at Temple University. There are onlyW a handful of research centers of its kind in the United States. Q: Integral? Lemole, an internationally known cardiovascular surgeon, A: Yes, the lymph system is integral to every system and has been fascinated with the lymphatic system since training process in the body, to the health of all organs and tissues. under transplant pioneers Debakey and Cooley at the Texas It maintains organ homeostasis by returning excess inter- Heart Institute in the 1960s. Today we know much more about stitial fluid to the circulation. It clears the body of dietary the lymphatic system, but it’s still a vastly understudied system fats, dead cells, cellular debris, and pathogens. It absorbs of the body, with many mysteries to decrypt. essential fatty acids — like vitamins A, D, and E — from the “Exciting discoveries await us at the Lemole Center that intestines and transports them to the blood. In addition, the could alter our approach to human disease,” says John M. Daly, lymphatic system is one of the most important components MD ’73, FACS, Interim Dean and Dean Emeritus of the medical of the human immune system, with major roles in innate school. “We’re grateful to the Lemoles. Transformative philan- and adaptive immunity. The contributions of the lymphatic thropy like this accelerates science.” system to health, to every function of the body, cannot be As the following discussion reveals, the lymphatic system — and overstated. Untreated lymph-related illness can be serious,

Lemole’s appreciation for it — run deep. even deadly. KHAN/FOTOBUDDY SAMEER

48 | TEMPLE HEALTH MAGAZINE | WINTER 2021 Q: In 1981, with an article you wrote that was published in the There are intimate connections between the lymphatic system Annals of Thoracic Surgery, you became the first to recognize and every system in the body that we’ve only just begun to identify lymphatic dysfunction in the origins of cardiac atherosclerosis. and explore. I’m excited. We’re entering a portal that just might In 2016, you revisited the topic in the journal. alter our approaches to medicine in fundamental ways. A: Little was known in 1981 about lymphatic filtration in the clearance of lipids from the coronary wall, but I believed that deficiency in that process — lymphostasis — was a critical factor in the development of atherosclerosis, and now we know this to be true. There is a strong association between defects in cardiac lymphatic function and the progression of cardiovascular disease. Therapies to improve lymphatic flow could advance the prevention and treatment of atherosclerotic disease. In fact, Michael Autieri, PhD, the director of our new research center, is looking into this. His lab is pinpointing the role of lymphatic vasculature in driving or resolving the atherosclerotic process. And he’s identified a potential therapeutic agent: A cytokine called interleuken-19, which holds great promise as a therapeutic agent with potent anti-inflammatory, anti-atherosclerotic, and pro-angiogenic actions. About seven other lymphatics research projects are already underway at the Center related to the heart and brain. It’s exciting.

Q: What is your vision for the Center? A: It’s been my lifelong goal to see lymphatics gain greater attention and appreciation within the scientific and medical communities. The work that will be done in the Lemole Center will help get us there — positioning Temple to compete for NIH grant funding in lymphatics, forging scientific progress, educating seasoned professionals and students, publishing, raising awareness — and ultimately improving patient care. The Lemole Center is multidisciplinary, yet integrated around a Michael Autieri, PhD, Director of the Lemole Center for Integrated lymphatics focus. Clinicians and scientists will collaborate to seek Lymphatics Research, is a respected educator and research out new insights into the lymphatic system and its roles in human leader who has been on the Temple faculty since 1998. He’s also health and disease. The goal is clinical impact. To advance ap- Associate Director of the Cardiovascular Research Center and proaches to detecting, preventing, and treating not just lymphatic holds professorships in the Sol Sherry Thrombosis Research system issues but many disease states, including edema, infarction, Center, Center for Metabolic Disease Research, and Department atherosclerosis, and neurodegeneration. of Physiology.

About Gerald Lemole, MD

A 1962 graduate of the Lewis Katz Lemole has had a distinguished Throughout, he’s remained close School of Medicine, Gerald Lemole, MD, career. His leadership contributions to Temple as a major benefactor and has accrued many “firsts.” include roles as Chief of Surgery at leader. He chaired LKSOM’s Board of In 1968 he was part of the team that Deborah Heart and Lung Center (New Visitors from 2011 to 2014, established performed the first heart transplant Jersey); Chief of Cardiovascular Surgery the Lemole Lecture Series in Integrative in the U.S. In 1969 when he returned at the Medical Center of Delaware; Medicine, and named a major confer- to Temple as Chief of Cardiothoracic and the W. L. Samuel Carpenter III ence center in the school’s Medical Surgery, he performed the first Distinguished Chair of Cardiovascular Education and Research Building. coronary bypass surgery in the tristate Surgery at the Christiana Care Health Lemole is currently writing a book about region. System in Delaware. the lymphatic system. JOSEPH V. LABOLITO V. JOSEPH

WINTER 2021 | TEMPLE HEALTH MAGAZINE | 49 Carson D. Schneck, MD ‘59, PhD ‘65

Hirsh’s Gift Expands Schneck’s Legacy

n excellent teacher can change a life “But it was really Dr. Schneck who showed me that I could and deepen a lifelong connection to the become a doctor,” Hirsh says. University where it all began — and for me, that teacher was Carson Schneck. He’s RITE OF PASSAGE an extremely brilliant man who taught Medical students take several courses during their first “Aanatomy at Temple for 50 years,” says S. Jay Hirsh, MD, a 1970 semester of medical school, but Human Gross Anatomy is the graduate of Lewis Katz School of Medicine. standout — in Hirsh’s words, “the portal into medicine, a rite To honor his mentor — and benefit anatomy students of today of passage.” and tomorrow — Hirsh donated $1 million to create the S. Jay Hirsh commends Temple for still using cadavers to teach Hirsh, MD Endowed Anatomy Lab Fund. It’s dedicated to keep- anatomy while an increasing number of medical schools are ing the Carson D. Schneck Gross Anatomy lab outfitted with the using virtual and digital resources as an alternative to cadaver- latest tools and technologies. based dissection. Medical students at Temple still work their way “I remember working on cadavers like it was yesterday. It was across the human body, dissecting specific regions and identify- a tough time, but the best of times, too,” says Hirsh, a urologist ing components of anatomy. This process has not changed much in Chester County, PA. since Hirsh’s student days — but the setting definitely has. “Dr. Schneck and the other faculty — all fantastic — taught us Hirsh’s class — all classes between 1969 and 2008 — took to respect the body and the wealth of information it imparts in Gross Anatomy in a windowless room in the Kresge Building.

life and after death. Then, in 2009, Temple opened a stunning new building featuring MATERIAL ARCHIVAL SCHOOL MEDICAL

50 | TEMPLE HEALTH MAGAZINE | WINTER 2021 Above: S. Jay Hirsh, from the 1970 Skull. Opposite: Carson D. Schneck, MD ’59, PhD ’65, the beloved alumnus who taught at the Lewis Katz School of Medicine for five decades. He was the first Anatomy and Cell Biology faculty member to earn a second doctoral degree while working full time — a degree in Diagnostic Imaging — from Temple.

a high-tech, spacious gross anatomy suite bathed in natural light. — and Carson Schneck was masterful at it,” Popoff says. Alumni mounted a campaign to name it for the enormously Hirsh concurs. He remembers Schneck illuminating clinical popular Schneck. Hirsh contributed, but “knew I had to do more, scenarios that students were likely to encounter in practice although I wasn’t sure what at the time,” he recalls. someday. “Gross anatomy is an immersive experience that draws not IT COMES TOGETHER just on superior teachers but also on superior technology — According to Steven Popoff, PhD, the John F. Huber Professor and and that’s where I come in — with a donation to help keep the Chair of the department, in the Schneck suite, students get practi- Schneck lab at the cutting edge for years,” says Hirsh. cal experience not just in anatomy but in diagnostic imaging. Popoff calls the fund “a perfect way to amplifyCarson “We use X-rays, CT, and MRI in tandem with dissection to teach Schneck’s legacy.”

FOR THE FAMILY Hirsh says he’d wanted to make a “That feeling of belonging is why I succeeded in significant gift to the Katz School for a long time; it just took some brain- becoming a doctor — and also why I became a donor,” storming with Popoff and themedical school’s Advancement staff to pinpoint Hirsh says. the opportunity. “My days in the Temple anatomy lab students to identify normal and abnormal anatomy. It’s all part of taught me a great deal besides anatomy,” he says. “I learned that an approach to teaching called clinical correlation,” he explains. I was part of a group on a long journey to becoming a doctor, to Clinical correlation puts anatomy in context, Popoff says, joining the medical family. drawing on multiple sources of information — physical exam “Dr. Schneck knew how to teach and what to teach,” says findings, blood and imaging study results, a patient’s symp- Hirsh. “His heart was big, his knowledge encyclopedic. Temple toms and medical history — to create a full clinical picture. For was the first institution to make me feel that I really belonged — example, when students study cranial nerves, they learn about and Dr. Schneck was a big part of that. diseases and injuries that affect nerve function. “That feeling of belonging really got me through medical “It’s a far more practical approach than memorizing structure school. It’s why I succeeded in becoming a doctor — and it’s also

HIRSH AND SCHNECK: MEDICAL SCHOOL ARCHIVAL MATERIAL; STUDENT: RYAN S. BRANDENBERG S. RYAN STUDENT: MATERIAL; ARCHIVAL SCHOOL MEDICAL AND SCHNECK: HIRSH without gaining an understanding of their clinical relevance why I became a donor,” he says.

WINTER 2021 | TEMPLE HEALTH MAGAZINE | 51 SO NOTED

“It is a true blessing to learn medicine in a DURING THE FIRST community that encourages us to prioritize the 3 MONTHS OF THE COVID-19 human aspect in everything we do.” PANDEMIC, — DANIEL ELCHEDIAK, CANDIDATE, MD CLASS OF 2023 91 For the 3rd consecutive year, Temple DURING THE 2020 MEDIA OUTLETS — University Hospital earned the designation FISCAL YEAR, TEMPLE INCLUDING of “LGBTQ Healthcare Equality Leader,” HEALTH SUPPORTERS THE NEW YORK scoring 100 out of 100 in the 13th edition of DONATED NEARLY TIMES, the Human Rights Campaign Foundation’s $42 MILLION IN GIFTS AND NEW ROLLING STONE, Healthcare Equality Index report. PLEDGES — A SUM PEOPLE, AND REPRESENTING ROUGHLY TIME — “WHERE THERE ARE OPTIONS — 40 PERCENT FEATURED OF TEMPLE UNIVERSITY’S AND TEMPLE GAVE ME MANY — RECORD-BREAKING 96 THERE IS HOPE.” $107.7 MILLION TEMPLE HEALTH — ROBERT SWEETIN, TEMPLE LUNG TRANSPLANT PATIENT FUNDRAISING YEAR. FACULTY, STAFF, Temple University “Providing high-quality AND STUDENTS IN Hospital Stats, 2019 health care to underserved

$93.5 M communities has been a 300+ Professional Education hallmark of Temple University ARTICLES Investment AND for more than a century.” BROADCASTS. $40.2 M — RICHARD ENGLERT, PRESIDENT, TEMPLE UNIVERSITY Charity Care Investment “What counts most in the long arc of adult life is not $19.5 M brilliance or charisma or panache, but rather the quality Subsidized Health the Romans called ‘gravitas’: patience, stamina, and Services weight of judgment.”

$12.5 M — PAUL MATHER, MD, PROFESSOR, UNIVERSITY OF PENNSYLVANIA; LKSOM ALUMNUS, 1988 Community Improvement Investment 148 TEMPLE FACULTY PHYSICIANS representing $520 M 42 SPECIALTIES were named TOP DOCTORS by Salaries & Benefits Philadelphia magazine in 2020.

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Gordon Gave a Hoot This patinated bronze owl, part of the Woodmere Art Museum In the early 1970s, upon learning that the land (then state- collection in Philadelphia, is the Temple University mascot as owned) was slated for commercial development, Gordon mount- interpreted by Kenneth H. Gordon Jr., MD ’48. ed the campaign to save it. He lobbied Congress, created petitions A child psychiatrist and sculptor, Gordon (1924-2005) was signed by thousands of voters, and presented testimony to three President of Temple’s medical alumni association from 1995 to separate congressional committees in Washington, D.C. 1997 and for a time also served on the school’s faculty. Gordon devoted five years to saving the land symbolic of the But more than just a loyal Temple Owl, Gordon is to credit for American struggle for independence. In 1975, his efforts finally

PHOTO COURTESY OF THE WOODMERE ART MUSEUM ART THE WOODMERE OF COURTESY PHOTO preserving a national historic treasure: Valley Forge National Park. paid off. Every year, the park attracts well over a million visitors.

WINTER 2021 | TEMPLE HEALTH MAGAZINE | 53 NON-PROFIT Temple HealthMagazine ORGANIZATION Lewis Katz School of Medicine at Temple University U.S. POSTAGE Temple University Health System PAID Office of Communications PHILA, PA 3509Temple N. Broad Street Health PERMIT 5140 Philadelphia, PA 19140 Magazine

Temple Health Magazine

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